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Discharge summary
|
report
|
Admission Date: [**2126-10-15**] Discharge Date: [**2126-10-23**]
Date of Birth: [**2048-3-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Unstable VTach
Major Surgical or Invasive Procedure:
Ventricular Tachycardia Ablation
History of Present Illness:
78yoM with h/o DM2, unclear CAD but reported stents/CABG who
developed chest heaviness after having 4 BM's this morning;
described as substernal pressure, no radiation, associated with
diaphoresis. He went to lay back down and the chest heaviness
persisted, he started feeling restless, then got up out of bed
and started feeling very dizzy; at which point he called his
nephew [**Name (NI) **]. EMS found him to be in ? VTach in the 160-170's and
was taken to [**Hospital3 **].
.
There, he had been having chest pressure for about 6 hrs. He was
initially responsive with BP's 94/40's and EKG was concerning
for stable VTach. He was Amiodarone 150mg bolused however then
reportedly became unresponsive and was cardioverted with 200J's
with resultant sinus rhythm in the 60's, and SBP's in the 90's.
His blood pressure then dropped to 70/40's and he received 0.1mg
Epinephrine with resultant BP's 130/70's and HR 50-70's, which
is near his current vitals [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] signout. Respiratorily,
he is RR 25-30's and 100% on NRB. EKG most recently shows NSR
with 1st degree AVB, inferolateral depressions, and <1 mm
elevations in aVR and V1. Through [**Hospital1 **], he also received 2L NS
and 3mg Versed. Labs showed a negative TropI at <0.06 (<0.39),
WBC 12.3 and Hct 26, BUN/Cr 24/1.8. (see below)
.
He was transferred on Amiodarone gtt, Heparin 950/hr, and
reportedly received ASA 81 mg x4, no Plavix.
.
ROS is mostly notable for what he reports as "bloody stool" for
the past 3 months, described as "pink" or marroon, and states
his last colonoscopy was 3 yrs ago and was OK. Otherwise, no
fevers/chills/sweats, cough, SOB, n/v, abd pain, diarrhea,
constipation, dysuria, BPH sxs, skin changes, lower extremity
edema. All of the other review of systems were negative.
.
Cardiac review of systems is notable for lack of chest pain
other than that described above. He notes exertional fatigue
worsening over the past year, having to take more frequent
breaks, and with soreness of his ankles, but no angina or clear
SOB. No PND, orthopnea. He states he gets what sounds like an
echo ? 1-2 times per year that have been normal.
Past Medical History:
1. CARDIAC RISK FACTORS: States he was recently diagnosed with
DM, but no insulin only orals. Denies HTN (states his BP is
always low).
2. CARDIAC HISTORY: None currently known - denies CABG, stents,
cath
3. OTHER PAST MEDICAL HISTORY:
- Syncopal episode 1 yr ago for which he was evaluated at ?
[**Last Name (un) **] and [**Location 1268**] VA and treated for ? Lyme disease?
- Colon ca s/p colectomy [**2114**] or [**2115**]
- "Trouble walking" for which he recently started using a cane
Social History:
Lives by himself at an apartment complex for the elderly. Not
married, no children; has 2 sisters and a nephew [**Name (NI) **]. [**Name2 (NI) **]
he's independent with his ADL's but gets help with paying his
bills and doing finances. Recently more difficulty with walking
so using a cane.
- Tobacco history: Quit 1 yr ago but smoked 1-1.5 ppd for 65 yrs
- ETOH: Used to drink but quit 17 yrs ago
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death.
- Mother: Deceased of cancer
- Father: Deceased of "shock"
- Sisters x2: healthy
Physical Exam:
Admission PE:
126/72 (83-126) p53 (50's) 13 96% 2L NC 82kg
Average sized elderly M in no distress, appears well, fair
historian. Appears grossly pale, with pale conjunctivae. EOMI,
no scleral icterus. Mouth and lips are dry. No JV pulsations
noted or HJR.
CTAB no w/c/r, good air movement
Faint S1/S2, S2 is louder, no murmurs, no heaves. No gallops.
Abd obese, NT ND, soft
Extremities are warm, not mottled, no BLE edema. Toenails are
very long.
CN 2-12 intact, no gross neuro deficits noted, moving all
extremities, conversant, speech fluent, mood/affect appropriate
Discharge PE:
Vitals - Tm/Tc: 98.2/97.9 HR: 68-88 BP: 101-109/58-69 RR: 18 02
sat: 98% RA
In/Out:
Last 24H: 1040/500+
Last 8H: 200/100
Weight: 80.7(80.8)
.
GEN: in no acute distress. Alert, lying flat in bed.
NECK: JVP at 10cm
RESP: no crackles, good air movement
CV: Faint S1/S2, S2 is louder, no murmurs, no heaves. No
gallops.
Extremities: warm, no BLE edema. Toenails are very long.
Neuro: CN 2-12 intact, no gross neuro deficits noted, moving all
extremities, conversant, speech fluent, mood/affect appropriate.
Gait steady.
Pertinent Results:
Admission Labs:
[**2126-10-15**] 10:44AM BLOOD WBC-12.5* RBC-3.15* Hgb-8.4* Hct-26.5*
MCV-84 MCH-26.7* MCHC-31.8 RDW-16.5* Plt Ct-465*
[**2126-10-17**] 04:23AM BLOOD Neuts-79.4* Lymphs-12.6* Monos-5.4
Eos-1.9 Baso-0.7
[**2126-10-18**] 06:15AM BLOOD Neuts-82.8* Lymphs-10.8* Monos-4.5
Eos-1.4 Baso-0.4
[**2126-10-15**] 10:44AM BLOOD PT-13.4 PTT-29.1 INR(PT)-1.1
[**2126-10-15**] 04:57PM BLOOD Ret Aut-2.8
[**2126-10-15**] 10:44AM BLOOD Glucose-165* UreaN-24* Creat-1.6* Na-143
K-5.1 Cl-114* HCO3-19* AnGap-15
[**2126-10-15**] 10:44AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.0
[**2126-10-15**] 04:57PM BLOOD calTIBC-490* Hapto-157 Ferritn-8.0*
TRF-377*
[**2126-10-15**] 05:33PM BLOOD Lactate-2.5*
[**2126-10-15**] 06:42PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2126-10-15**] 06:42PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2126-10-15**] 06:42PM URINE RBC-<1 WBC-4 Bacteri-NONE Yeast-NONE
Epi-0
[**2126-10-15**] 06:42PM URINE Hours-RANDOM UreaN-582 Creat-262 Na-30
K-GREATER TH Cl-63
[**2126-10-15**] 06:42PM URINE Osmolal-580
Notable Labs:
[**2126-10-15**] 10:44AM BLOOD CK(CPK)-157
[**2126-10-15**] 04:57PM BLOOD LD(LDH)-239 CK(CPK)-502* TotBili-0.2
[**2126-10-16**] 02:46AM BLOOD CK(CPK)-404*
[**2126-10-15**] 10:44AM BLOOD CK-MB-20* MB Indx-12.7* cTropnT-0.12*
[**2126-10-15**] 04:57PM BLOOD CK-MB-71* MB Indx-14.1* cTropnT-0.56*
[**2126-10-16**] 02:46AM BLOOD CK-MB-49* MB Indx-12.1* cTropnT-0.62*
Discharge Labs:
Micro:
Urine culture from [**2126-10-16**] and Blood culture from [**2126-10-15**] no
growth to date
Portable TTE (Complete) Done [**2126-10-15**]
Left Ventricle - Ejection Fraction: 30%
TR Gradient (+ RA = PASP): *32 to 37 mm Hg
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. LV systolic function appears depressed
(ejection fraction 30 percent) secondary to severe
hypokinesis/akinesis of the inferior and posterior walls. The
lateral wall is also hypokinetic. The right ventricular free
wall thickness is normal. Right ventricular chamber size is
normal. with depressed free wall contractility. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
CHEST (PORTABLE AP) Study Date of [**2126-10-15**]
No previous images. There is enlargement of the cardiac
silhouette
with evidence of pulmonary vascular congestion. No definite
pleural effusion or acute focal pneumonia.
EP Report: [**2126-10-17**]:
EP study + ablation of ventricular tachycardia
Conclusions:
1. Monomorphic VT with 3 different morphologies, all RBBB
superior axis arising from region of basal inferior scar,
however, none were consistent with clinical VT (RBBB inferior
axis leads)
2. Predominant morphology was RBBB superior axis, positive
across precordial leads, most isoelectric in I and V6 with CL of
380ms, well tolerated hemodynamically
3. Moderate sized basal inferior and inferolateral scar by
voltage mapping
4. Multiple sites with late potentials and fractionated egms
5 substrate ablation targeting late potentials, which did not
affect either the VT or the late potentials suggesting
epicardial circuit/origin of VT
6. Mechanism of VT unclear with features to support both
reentry (entrainment with fusion) as well as focal (facilitation
with catechols and induction with burst pacing).
.
[**2126-10-15**] 6:02 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2126-10-21**]**
Blood Culture, Routine (Final [**2126-10-21**]): NO GROWTH.
.
.
[**2126-10-16**] 10:27 pm URINE Source: Catheter.
**FINAL REPORT [**2126-10-18**]**
URINE CULTURE (Final [**2126-10-18**]): NO GROWTH.
.
.
.
[**2126-10-18**] 06:15AM BLOOD Neuts-82.8* Lymphs-10.8* Monos-4.5
Eos-1.4 Baso-0.4
[**2126-10-15**] 04:57PM BLOOD Ret Aut-2.8
[**2126-10-15**] 10:44AM BLOOD CK-MB-20* MB Indx-12.7* cTropnT-0.12*
[**2126-10-15**] 04:57PM BLOOD CK-MB-71* MB Indx-14.1* cTropnT-0.56*
[**2126-10-16**] 02:46AM BLOOD CK-MB-49* MB Indx-12.1* cTropnT-0.62*
[**2126-10-15**] 04:57PM BLOOD calTIBC-490* Hapto-157 Ferritn-8.0*
TRF-377*
.
[**2126-10-23**] 06:30AM BLOOD WBC-12.6* RBC-3.38* Hgb-9.1* Hct-26.8*
MCV-79* MCH-26.9* MCHC-33.9 RDW-19.7* Plt Ct-429
[**2126-10-23**] 06:30AM BLOOD Neuts-77.1* Lymphs-16.0* Monos-3.1
Eos-2.9 Baso-0.9
[**2126-10-23**] 06:30AM BLOOD PT-29.7* INR(PT)-2.9*
[**2126-10-23**] 06:30AM BLOOD Glucose-106* UreaN-43* Creat-1.6* Na-137
K-4.8 Cl-105 HCO3-18* AnGap-19
[**2126-10-23**] 06:30AM BLOOD Mg-2.3
Brief Hospital Course:
Assessment and Plan
78yoM with unclear PHx including CAD who presented to [**Hospital1 **]
with chest pressure and found to have monomorphic VTach s/p
cardioversion, transferred to [**Hospital1 18**] out of concern for ACS; on
admission, pt was stable and in sinus rhythm.
.
1. Idiopathic ??????benign?????? VT: Appears to have been unstable at
[**Hospital1 **] for which he received 200J shock. Pt was started loaded
with amiodarone and transitioned to 200mg daily. Reversible
causes of monomorphic VT include infections, new onset ischemia,
hypoxia and anemia. Although pt had elevated cardiac enzymes,
he did not complain of typical anginal pain prior to or after
shocks, and he did not have any significant changes on EKG from
baseline. PT was anemic throughout hospital stay (see below,
but no evidence of acute drop in hct). Pt had leukocytosis on
admission but was afebrile and infectious workup was negative
with unremarkable blood, urine cx. On HD2 pt went for EP study
and ablation. EP study revealed monomorphic VT with 3
morphologies all of which were RBBB arising from basal inferior
scar. A substrate ablation was done but did not affect VT or
late potentials suggesting epicardial circuit as source of VT.
Uncertain if source was reentrant or focal. Pt was continued on
amiodarone and did not experience anymore episodes of [**Hospital **]
[**Hospital 68241**] hospital course. He did develop new onset afib (see
below). Pt was prepped for cardiac MRI but had [**Last Name (un) **] [**3-13**]
over-diuresis on day of scheduled MRI putting him at risk for
dye load. Pt will be scheduled for outpatient CMRI to assist in
mapping anatomy for future epicardial VT ablation.
.
#A.[**Name (NI) 6233**] Pt developed newfound afib on HD5. He was asymptomatic,
and remained in afib throughout hospital course. Chads2 >4. He
was started on metoprolol for rate control and continued on
amiodarone. Rates were controlled at 80-110 BPM and he was
started on heparin gtt with bridge to coumadin. On [**10-21**] INR
became therapeutic at 2.2 on 2.5 mg of coumadin. He will need
to have outpt physician follow INR. At time of discharge, he
was on metoprolol XR 75mg daily.
.
#CHF: Has history of systolic heart failure and on echo had LVEF
of 30% with inferior, posterior and lateral walls severely
hypokinetic suggestive of ischemic etiology. On HD 3, pt became
hypoxic secondary to flash pulmonary edema. He was given an
80mg IV bolus of lasix and lasix gtt at 5mg/hr and his O2 sats
and volume status improved over the next 24 hours after 2.5 L of
diuresis. He was diuresed and additional 2.5L over the next
several days resulting in hypovolemia and prerenal failure.
Lasix was temporarily held. On discharge he was on 20mg lasix
PO daily, lisinopril, and metoprolol succinate.
.
2. CAD: Pt denies any history of MI and has no history of
catheterization/stents or CABG and EKG does not show q waves
suggestive of prior MI. He does have regional wall motion
abnormalities on echo, suggestive of prior ischemia. On
admission his CE were elevated but no evidence of ACS on ekg or
history. CE bump likely secondary to demand ischemia in setting
of anemia with crit <30 and episodes of VT. 200J shock can also
cause trop leak. Pt was d/ced on ASA, gemfibrazil and meds as
mentioned above.
.
4. Anemia: Reported 3mo h/o "pink" stools and Hct 26 on arrival;
reports normal colonoscopy 3 yrs ago. Acute anemia could be
leading to cardiac ischemia and possibly explains his 1 yr h/o
increased fatigue on exertion. Anemia labs suggestive of Iron
deficiency. Crit dropped to approximately 22 w/o evidence of
active bleeding and he was transfused one unit of blood with an
appropriate increase in hct. GI was consulted and recommended
pt have outpt colonoscopy. He was also started on misoprostol
for GI prophylaxis while on ASA. Given iron deficiency,
discharged on ferrous sulfate as well.
.
6. CKD: Unclear baseline but Cr 1.8 when admitted to [**Hospital1 **]. He kidney function improved to 1.5 but after
aggressive diuresis in setting of flash pulmonary edema, pt's
creatinine rose to 2.1. BUN:Cr ratio suggestive of prerenal
etiology/overdiuresis. Lasix was temporarily held and
creatinine at time of discharge was 1.6.
.
7. Alcohol Abuse- As per pt's nephew, he has not had a drink in
17 years, but initially pt was started on thiamine, folate and a
multivitamin. Pt confirmed history of no recent EtOH abuse and
did not show any signs of withdrawal.
.
.
Transitional
- outpatient cardiac MRI and ultimately VT ablation of
epicardial source
- will need outpatient colonoscopy to workup anemia
- needs f/u chemistries to make sure [**Last Name (un) **] resolving
- PCP will manage coumadin/INR as outpatient
Medications on Admission:
gemfibrozil 600mg [**Hospital1 **]
lisinopril 5mg Qdaily
glipizide 5mg Qdaily,
atenolol 25mg Qdaily,
omeprazole 20mg Qdaily
lorazepam 0.5mg PRN;
Discharge Medications:
1. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO as needed as
needed.
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. misoprostol 200 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. Outpatient Lab Work
Please check INR, chem-7 on Friday [**10-24**] with results to Dr.
[**Last Name (STitle) **] at Pager [**Telephone/Fax (1) 98825**], ask to speak to covering RN
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Monomorphic Ventricular Tachycardia
Coronary Artery Disease
Atrial Fibrillation
CHF
Anemia
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were transfered to us from [**Hospital3 4107**]
after having a fast abnormal heart rhythm which resulted in you
receiving a shock to get your heart beating normally again.
While you were here you had a procedure to try and stop your
heart from going into a fast rhythm again. It was difficult for
the electrophysiologists to find the source of the fast heart
rate during the procedure. You were started on a medicine called
Amiodarone to help keep your heart in a normal rhythm instead.
You also had a cardiac MRI performed during this visit as well
to visualize the structures of your heart. Please weigh yourself
every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
The following changes have been made to your medicines:
STARTED:
Ferrous Sulfate 300mg daily
Amiodarone 200mg twice a day
Misoprostol 200mcg twice a day
Warfarin 2.5mg daily
Furosemide 40mg daily
CHANGED:
Lisinopril dose increased to 10mg daily
Please see below for follow up appointments that have been made
for you.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] VA - Cardiology
Address: [**Location (un) 98826**] BLDG 3, [**Hospital1 **],[**Numeric Identifier 8728**]
Phone: [**Telephone/Fax (1) 98827**]
Appt: [**10-31**] at 10am
.
Name: [**Last Name (un) 84199**],[**Name8 (MD) 98828**] MD - Gastroenterology
Location: [**Hospital6 **]
Address: [**Location (un) **], [**Location (un) 538**], MA
Phone: [**Telephone/Fax (1) 98829**]
Appt: [**11-4**] at 10am
.
Primary Care:
[**Last Name (LF) **], [**First Name3 (LF) **] HAINES
[**Telephone/Fax (1) 98830**]
[**11-8**] at 11:30am
.
[**Hospital 197**] clinic:
[**Telephone/Fax (1) 98831**] for any lab results or questions after Friday [**10-25**].
Dr. [**Last Name (STitle) **] will formally refer you to this clinic.
|
[
"250.00",
"427.1",
"428.23",
"V58.61",
"285.1",
"428.0",
"427.31",
"792.1",
"787.91",
"585.9",
"276.2",
"584.9",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
16207, 16262
|
9825, 14573
|
322, 357
|
16420, 16420
|
4876, 4876
|
17627, 18489
|
3568, 3739
|
14768, 16184
|
16283, 16399
|
14599, 14745
|
16528, 17604
|
6379, 9802
|
3754, 4325
|
2778, 2827
|
4339, 4857
|
268, 284
|
385, 2600
|
4892, 6362
|
16435, 16504
|
2858, 3114
|
2622, 2758
|
3130, 3552
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,954
| 130,192
|
29552
|
Discharge summary
|
report
|
Admission Date: [**2134-7-3**] Discharge Date: [**2134-7-9**]
Date of Birth: [**2070-10-28**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
This is a 63 yo F w/ CAD s/p multiple stents and CABG x 1 in
[**2132**] (LIMA to LAD) not on ASA/Plavix, AVR, and GI bleed who
presents s/p cardiac arrest. Per husband pt had some trouble
breathing for last few days. Felt weak last night, poor po.
Tonight she felt poorly, nauseous, uneasy. Had BM and tried to
vomit but was unable to do so. She had elevated blood sugars
around 300 so took an extra Avandia. Tonight, had episode of
gasping for air then stopped breathing- husband started CPR
while she was still on the couch (he ? if she possibly
aspirated) then called 911. This was around 1730. EMS arrived 15
minutes later and gaive 1 shock, epi, lidocaine, atropine.
Patient at that time had wide complex tachycardia without pulse.
She was then inutbated with RSI, fent, rocuronium. Patient went
to [**Hospital1 487**] then transferred to [**Hospital1 18**]. Started on hypothermia at
[**Hospital1 487**] and then continued on admission.
.
In the ED vitals were 130/86, 94, intubated. She was given ASA
325 and Plavix 300. Patient had head CT that showed no head
bleed. She was then started on ASA, Plavix, heparin gtt, and
lidocaine gtt. Once in the CCU an echo was done that showed new
wall motion abnormality. Patient was then taken to cath lab.
.
Of note patient was on plavix for 1 year with many bleeds and
blood transfusions. Still anemic at times and gets epo shots
prn.
.
ROS not completed since patient intubated.
Past Medical History:
- Coronary Artery Disease - s/p 2 Cypher stents to LAD in [**1-28**],
then angioplasty for LAD ISR in [**7-28**]
- Congestive Heart Failure(Systolic)
- Prior Mechanical Aortic Valve Replacement in [**2113**]
- History of GI Bleed secondary to AV Malformations of Small
Bowel and Stomach
- History of Stroke/TIA in [**2123**], no residual effects
- Carotid Disease, Left Carotid Atery Occlusion
- Hypertension
- Hyperlipidemia
- Type II Diabetes Mellitus
- Anemia secondary to GI Bleed
- Depression
- Anal Fissure Repair
- Hemorrhoidectomy
Social History:
Disabled
Lives with spouse
Smoked 1/2PPD for 25 years quit [**2130-12-22**]
No h/o EtOH or drugs
Family History:
Mother and father both died of MI in 60s; brother (age 69) has
heart murmur
Physical Exam:
GENERAL: Intubated, not responsive to painful stimuli
HEENT: Intubated, PERRL.
NECK: Supple, JVD difficult to appreciate
CARDIAC: RRR, 2/6 systolic murmur loudest at upper sternal
border
LUNGS: course breath sounds bilaterally
ABDOMEN: Soft, NTND. hypoactive bowel sounds
EXTREMITIES: no edema, cool feet
PULSES:
Right: 1+ radial, DP not palpable
Left: 1_ radial, DP not palpable
Pertinent Results:
Admission:
[**2134-7-3**] 11:40PM BLOOD WBC-19.4*# RBC-3.79* Hgb-11.1* Hct-35.6*
MCV-94# MCH-29.2 MCHC-31.1 RDW-18.2* Plt Ct-341
[**2134-7-3**] 11:40PM BLOOD PT-21.7* PTT-25.7 INR(PT)-2.0*
[**2134-7-3**] 11:40PM BLOOD Glucose-432* UreaN-35* Creat-1.6* Na-136
K-4.0 Cl-102 HCO3-20* AnGap-18
[**2134-7-4**] 12:32AM BLOOD Type-ART Rates-/12 PEEP-5 pO2-264*
pCO2-47* pH-7.27* calTCO2-23 Base XS--5 Intubat-INTUBATED
Comment-GREEN TOP
[**2134-7-3**] 11:45PM BLOOD Lactate-4.8*
[**2134-7-4**] 04:01PM BLOOD freeCa-1.09*
.
Cardiac Enzymes:
[**2134-7-3**] 11:40PM BLOOD CK-MB-40* MB Indx-8.9*
[**2134-7-3**] 11:40PM BLOOD cTropnT-0.41*
[**2134-7-3**] 11:40PM BLOOD CK(CPK)-447*
[**2134-7-4**] 05:00AM BLOOD CK-MB-87* MB Indx-11.4* cTropnT-0.85*
[**2134-7-4**] 05:00AM BLOOD CK(CPK)-761*
[**2134-7-4**] 04:00PM BLOOD CK-MB-96* MB Indx-14.3* cTropnT-1.1*
[**2134-7-4**] 04:00PM BLOOD CK(CPK)-673*
[**2134-7-5**] 06:21AM BLOOD CK-MB-83* MB Indx-10.2* cTropnT-1.55*
[**2134-7-5**] 06:21AM BLOOD CK(CPK)-814*
.
Discharge labs:
[**2134-7-9**] 05:51AM BLOOD WBC-10.7 RBC-2.61* Hgb-7.4* Hct-22.8*
MCV-87 MCH-28.3 MCHC-32.4 RDW-17.9* Plt Ct-322
[**2134-7-9**] 04:09AM BLOOD PT-18.4* PTT-25.6 INR(PT)-1.7*
[**2134-7-9**] 04:09AM BLOOD Glucose-121* UreaN-53* Creat-1.9* Na-135
K-3.7 Cl-101 HCO3-23 AnGap-15
[**2134-7-9**] 04:09AM BLOOD Calcium-7.7* Phos-4.3 Mg-2.7*
[**2134-7-9**] 06:27AM BLOOD Type-ART pO2-113* pCO2-33* pH-7.45
calTCO2-24 Base XS-0
.
[**2134-7-9**] CXR:
ET tube tip is 4.9 cm above the carina. NG tube tip is in the
stomach.
Moderate cardiomegaly is stable. Right IJ catheter tip is in
unchanged
position at the cavoatrial junction. Widened mediastinum with
engorgement of the vasculature is unchanged. Left lower lobe
atelectasis has markedly
improved. Perihilar and right lower lobe opacities have worsened
and
consistent with moderate pulmonary edema. There is no evident
pneumothorax.
.
[**2134-7-7**] EEG:
IMPRESSION: This video EEG telemetry captured no pushbutton
activations. No electrographic seizures or interictal
epileptiform
discharges were seen. The background was very low voltage on
this day
of recording with some visible beta frequency activity at times.
This
finding suggests the presence of a severe encephalopathy which
can occur
because of hypoxic ischemic injury, medications, metabolic
disturbances,
and other etiologies of diffuse brain dysfunction.
.
[**2134-7-5**] Echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
hypokinesis of the distal half of the septum and anterior walls,
and apex. The remaining segments contract normally (LVEF = 45
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of mitral regurgitation.] No masses
or thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. A well seated
mechanical aortic valve prosthesis is present. The prosthetic
aortic valve leaflets appear mobile, but the transaortic
gradient is higher than expected for this type of prosthesis.
Trace aortic regurgitation is seen. [The amount of regurgitation
present is normal for this prosthetic aortic valve.] The mitral
valve leaflets are mildly thickened. There is no mitral
stenosis. Severe (4+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD. Well seated mechanical AVR with mobile leaflets but
increased gradient. Severe mitral regurgitation. Mild pulmonary
artery systolic hypertension.
.
[**2134-7-4**] CT head:
No acute intracranial hemorrhage.
.
[**2134-7-4**] Cath:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated two
vessel disease. The LMCA had no significant disease. The LAD was
occluded proximally with filling of the mid-vessel in a
retrograde
fashion from the LIMA; the distal LAD filled via minimal
collaterals
from the LCx. The LCx had no significant disease. The RCA was
diffusely
disease and occluded in the mid segment; the distal vessel
filled
antegrade and via collaterals from the LCx.
2. Arterial conduit angiography revaeled the LIMA to be widely
patent up
until the distal anastamosis site with retrograde filling of the
mid LAD
but occlusion of the LAD distal to the graft without the
appearance of
an acute event.
3. Limited resting hemodynamics revealed mild systemic arterial
hypertension.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Patent LIMA-LAD with occlusion of the LAD distal to the
anastamosis
site of uncertain age not suitable for PCI.
3. Mild systemic arterial hypertension.
.
[**2134-7-4**] Echo:
There is mild to moderate regional left ventricular systolic
dysfunction with distal anterior, septal and apical akinesis.
The remaining segments are incompletely visualized but appear to
contract normally (LVEF = 35-40%). Right ventricular chamber
size and free wall motion are normal. A mechanical aortic valve
prosthesis is present. The aortic valve prosthesis cannot be
adequately assessed. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Mild to moderate regional left ventricular systolic
dysfunction c/w mid LAD-territory infarction. Moderate mitral
regurgitation. Mechanical aortic prosthesis - cannot assess
function.
Brief Hospital Course:
This is a 63 yo F w/ CAD s/p multiple stents and CABG x 1 in
[**2132**] (LIMA to LAD) not on ASA/Plavix, AVR, and GI bleed who
presents s/p cardiac arrest.
.
# S/P cardiac arrest: Patient was intubated and cooled per
Arctic Sun protocol. Echo was done that showed new wall motion
abnormality so patient was taken to cardiac catherization.
However, at catherization, no vessel was deemed necessary of
stenting. Patient had EEG that showed very limited neurological
activity. [**Name (NI) **] husband and family made patient [**Name (NI) 3225**] after
extensive discussion with CCU team and neurology. Patient passed
away on [**2134-7-9**].
.
# CAD s/p multiple PCI and CABG: Patient was on aspirin and
plavix. Patient had cardiac catherization per above.
.
# DM 2: Manged with insulin
.
# h/o GI bleed: Patient has a h/o GI bleed [**2-23**] AVMs. Patient's
HCT slowly trended down this hospitalization. However, patient
did not receive transfusion during hospial stay.
.
Medications on Admission:
Atorvastatin 20mg po qday
Docusate Sodium
Ferrous Gluconate 325mg po qday
Lisinopril 2.5mg po qday
Metformin 1g [**Hospital1 **]
Metoprolol Tartrate 25mg [**Hospital1 **]
Omeprazole [Prilosec] 20mg po qday
Rosiglitazone [Avandia] 4mg po qday
Sertraline [Zoloft] 25mg po qday
Warfarin 6mg po qday
Discharge Medications:
patient deceased [**2134-7-9**]
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient deceased [**2134-7-9**]
Discharge Condition:
Patient deceased [**2134-7-9**]
Discharge Instructions:
Patient deceased [**2134-7-9**]
Followup Instructions:
Patient deceased [**2134-7-9**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2134-7-9**]
|
[
"584.9",
"276.2",
"427.31",
"348.1",
"427.5",
"272.4",
"410.91",
"V45.82",
"V43.3",
"250.00",
"V45.81",
"414.00",
"401.9",
"428.23",
"311",
"507.0",
"285.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.22",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9957, 9966
|
8583, 9554
|
299, 311
|
10041, 10074
|
2957, 3473
|
10154, 10344
|
2464, 2541
|
9901, 9934
|
9987, 10020
|
9580, 9878
|
7623, 8560
|
10098, 10131
|
3971, 6763
|
2556, 2938
|
3490, 3955
|
241, 261
|
339, 1770
|
6772, 7606
|
1792, 2333
|
2349, 2448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,051
| 199,149
|
54686
|
Discharge summary
|
report
|
Admission Date: [**2159-4-24**] Discharge Date: [**2159-4-26**]
Date of Birth: [**2089-8-17**] Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Altered mental status and sepsis
Major Surgical or Invasive Procedure:
[**2159-4-25**] - PICC line placement
History of Present Illness:
69YOM with h/o HIV, CKD, [**Hospital 23051**] transferred from [**Hospital **] Rehab for
reports of AMS for the past couple weeks, and more so since
[**2159-4-22**]. Per nursing report at the rehab center, pt has been
confused (he is AAOx1 at baseline to self) and more so over the
past few weeks, has not had fevers/chills, or vomiting to the
RNs knowledge. RN endorses loose stools, belly pain, and hip
pain - reported positive urine cultures from [**2159-4-10**] and [**2159-4-14**]
with E.Coli, for which they started him on Augmentin on [**2159-4-10**].
The pt was also being treated for C.diff (positive on [**4-9**] at
[**Hospital1 **]) with PO vancomycin. Two days prior to this admission, pt
was more somnolent and difficult to arouse, had more difficulty
walking; he has had a progressive decline over the past few
months.
In the ED, initial VS were: 100.8 ??????F (38.2 ??????C) (Rectal), Pulse:
93, RR: 14, BP: 110/83, O2Sat: 96%, O2Flow: (Room Air), Pain:
10. EKG was done, which showed SR @ 84, baseline artifact, no
peaked t-waves. CXR was done, which showed RLL opacity,
concerning for atelectasis, pneumonia cannot be excluded in the
appropriate clinical setting. CT head showed no acute
intracranial process and volume loss out of proportion to
patient's age and non-specific white matter hypodensities may
relate to underlying HIV. UA and urine culture was taken from
his uterostomy. He was given 1L NS, ibuprofen and meropenem.
Vitals upon transfer were BP 122/95, RR 16, HR 84, Sat 95%.
On arrival to the MICU, patient's VS. Pt is resting comfortably
with complaints of R leg pain that he usually has. Denies other
pain. He endorses poor appetite with a 5lb weight loss over the
past week. Denies cough, chest pain, abd pain, or nausea. Denies
diarrhea or urinary complaints. He is alert and interactive but
oriented x2. Baseline reported as A&Ox1 to self.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies cough, chest pain, chest
pressure, palpitations. Denies abdominal pain, diarrhea, dark or
bloody stools. Denies dysuria, frequency, or urgency. Denies
rashes or skin changes.
Past Medical History:
Anemia
Anxiety
Dementia
Bipolar d/o
R troch avulsion fx
Bladder ca s/p urostomy
CKD
Depression
DM
Emphysema
GERD
HIV
Cdiff
Latent syphilis
Neuropathy
Osteopenia
h/o pyelo
Schizoprhenia
Tremors
UTIs
Social History:
Has been at the [**Hospital **] Rehab since [**2-5**].
Family History:
Patient adopted
Physical Exam:
Admission exam:
General: Cachectic, Alert & oriented x2, calm but thirst/hungry,
NAD
HEENT: Eyes sunken, sclera anicteric, MM dry, oropharynx clear,
adentulous, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2 but distant heart
sounds, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: R ureterostomy non TTP
Ext: Cool extremities, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
gait deferred.
Discharge exam:
VSS
GEN: Patient lying comfortably in bed nad a+ox1
HEENT: MMM oropharynx clear
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: ctab no w/r/r
ABD: soft nt nd bs+
EXTR: no le edema good pedal pulses bilaterally left sided picc
line in place
DERM: no rashes, ulcers or petechiae
neuro: cn 2-12 grossly intact non-focal
Pertinent Results:
Admission labs:
[**2159-4-24**] 02:20PM BLOOD WBC-12.2* RBC-4.40* Hgb-14.7 Hct-48.3
MCV-110* MCH-33.5* MCHC-30.5* RDW-16.1* Plt Ct-392
[**2159-4-24**] 02:20PM BLOOD Neuts-75.5* Lymphs-21.1 Monos-2.5 Eos-0.4
Baso-0.5
[**2159-4-24**] 02:20PM BLOOD WBC-12.2* Lymph-21 Abs [**Last Name (un) **]-2562 CD3%-60
Abs CD3-1545 CD4%-26 Abs CD4-662 CD8%-33 Abs CD8-850*
CD4/CD8-0.8*
[**2159-4-24**] 02:20PM BLOOD Glucose-119* UreaN-45* Creat-1.6* Na-131*
K-GREATER TH Cl-102 HCO3-19*
[**2159-4-24**] 02:20PM BLOOD ALT-25 AST-130* AlkPhos-58 TotBili-0.5
[**2159-4-24**] 02:20PM BLOOD Albumin-4.0
[**2159-4-24**] 02:25PM BLOOD Lactate-2.5* K-5.4*
[**2159-4-25**] 05:10AM BLOOD Lactate-1.7
Discharge labs:
Imaging:
-CXR ([**2159-4-24**]): Right lower lung opacity, most likely
atelectasis, however, pneumonia cannot be excluded in the
appropriate clinical setting.
-CT head ([**2159-4-24**]):
1. No acute intracranial process.
2. Volume loss out of proportion to patient's age and
non-specific white
matter hypodensities may relate to underlying HIV. If high
clinical suspicion for other an alterantive diagnosis, a MRI
could be performed.
Discharge labs
[**2159-4-26**] 05:30AM BLOOD WBC-8.4 RBC-2.92* Hgb-9.8* Hct-31.0*
MCV-106* MCH-33.6* MCHC-31.6 RDW-16.0* Plt Ct-270
[**2159-4-26**] 01:42PM BLOOD Hct-33.1*
[**2159-4-26**] 11:45AM BLOOD Glucose-81 UreaN-24* Creat-0.8 Na-137
K-4.5 Cl-112* HCO3-16* AnGap-14
[**2159-4-25**] 03:44AM BLOOD ALT-13 AST-15 AlkPhos-47 TotBili-0.3
Brief Hospital Course:
# ESBL UTI: Patient was being treated with Augmentin at rehab
which is inappropiate coverage for ESBL E. coli. He was changed
to meropenem at arrival and a PICC line was placed for him to
receive antibiotics after discharge. He will need to continue
meropenem for 8 more days(end date [**2159-5-4**])
# AMS: Mental status appeared to be at his baseline of A&Ox1
upon arrival to the ICU. His prior AMS was thought to be due to
his undertreated ESBL E. coli infection, as described above.
# Possible PNA: Possible PNA seen on admission CXR in LLL; but
no cough or pulmonary complaints. He will be treated with
meropenem for his ESBL E. coli UTI as above which should cover
most typical pneumonia pathogens.
# C. diff colitis: Positive for C. diff on [**4-9**] at [**Hospital1 **]. Not
currently having diarrhea. He was continued on PO vancomycin
which will need to be continued for 2 weeks after his meropenem
course is completed (end date [**5-17**])
# Acute on chronic kidney failure: Baseline Cr [**First Name8 (NamePattern2) **] [**Hospital1 **]
records is about 1.1. He was pre-renal at arrival with Cr of
1.6. His creatinine returned to baseline at 0.8 on day of
discharge.
#macrocytic anemia: noted on day of discharge-appears to be
dilutional. No acute signs of bleeding. [**Month (only) 116**] be [**1-11**]
antiretroviral medications. Folate and B-12 checked and pending
at discharge.
# HIV ?????? unclear when he was diagnosed, [**Name (NI) 14904**] at admission was 662
suggesting that his HIV is well controlled and he is not
significantly immunosuppressed. He was continued on his home
antiretrovirals: Epzicom (abacavir-lamivudine 600-300mg) and
kaletra 2 tabs.
# Code status this admission: FULL
# Transitional issues
-Continue meropenem for a total of 10 days
-continue vancomycin po for 14 days after completing meropenem
course
-Check cbc, chem 10 panel on [**2159-4-30**]
-follow up on b12/folate levels
Medications on Admission:
PO vancomycin 125mg PO q6hr
Augmentin
Bupropion XL 300mg daily
Calcium carbonate 1000mg PO qday
Divalproex capsule Sprinkle 375mg TID at 9a, 1p, 5p
Epzicom 600-300mg qHS
Gabapentin 400mg q12hr
Kaletra 200-50, two tablet PO qHS
Clonazepam 0.5mg PO q12hr, and 0.5mg PO daily prn Anxiety
Lactobacillus 1 tab PO qAC
Meclizine 12.5mg q12hr
Megace ES 625mg/5mL, 5mL PO daily
Melatonin 3mg PO qHS
MVI
Oxycodone 5mg TID at 9a, 1p, 9p; also 5mg PO q4hr prn
breakthrough
Trazodone 100mg PO qHS
Vitamin D3 1000U daily
Ranitidine 150mg PO daily
Bisacodyl 10mg PR prn
Milk of magnesia prn constipation
Mylanta prn dsypepsia
APAP 650mg PO q6hr prn pain
Discharge Medications:
1. vancomycin 250 mg/5 mL Syringe Sig: One [**Age over 90 **]y Five
(125) mg PO Q6H (every 6 hours) for 22 days: End date [**2159-5-17**].
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
4. divalproex 125 mg Capsule, Sprinkle Sig: Three (3) Capsule,
Sprinkle PO TID (3 times a day).
5. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Kaletra 200-50 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
9. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO PRN (as needed) as needed for constipation.
11. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Five (5)
ml PO DAILY (Daily).
12. melatonin 3 mg Tablet Sig: One (1) Tablet PO qHS ().
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
15. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
17. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. bisacodyl 10 mg Suppository Sig: One (1) Rectal prn as
needed for constipation.
19. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 8 days.
Disp:*24 Recon Soln(s)* Refills:*0*
20. Outpatient Lab Work
Please check cbc, chem 10 panel on [**4-30**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
ESBL UTI
c.diff colitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with altered mental status found to have a
urinary tract infection. Your symptoms improved with hydration
and antibiotics. You will need to continue IV antibiotics for a
total of 10 days. Please have a follow up cbc and chem 10 panel
on [**4-30**] at your [**Hospital1 1501**]
New medication
1. Meropenem IV q6h for a total of 10 days(end date [**2159-5-4**])
2. Please continue oral vancomycin for 14 days after completing
meropenem(end date [**2159-5-17**])
Followup Instructions:
Please follow up with the physician at your skilled nursing
facility
|
[
"281.9",
"V10.51",
"250.00",
"530.81",
"733.90",
"041.49",
"008.45",
"296.80",
"599.0",
"294.10",
"295.90",
"V08",
"584.9",
"585.9",
"V44.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9785, 9858
|
5383, 7323
|
323, 362
|
9926, 9926
|
3886, 3886
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10584, 10656
|
2822, 2839
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8012, 9762
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9879, 9905
|
7349, 7989
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10079, 10561
|
4580, 5360
|
2854, 3522
|
3538, 3867
|
2291, 2512
|
251, 285
|
390, 2272
|
3902, 4563
|
9941, 10055
|
2534, 2734
|
2750, 2806
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,255
| 105,835
|
52400
|
Discharge summary
|
report
|
Admission Date: [**2175-8-19**] Discharge Date: [**2175-9-12**]
Service: SURGERY
Allergies:
Aspirin / Azithromycin / Codeine
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
traumatic brain injury/stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87M with a history of hypertension and renal insufficiency not
anticoagulated who presents from an outside hospital after a
fall from standing. The patient was at a wedding when he
reportedly fell without breaking his fall. He was transferred to
[**Hospital **] Hospital where he was intubated for a GCS 8. Head CT at
the OSH reveals bilateral subarachnoid hemorrhages with
associated intraventricular hemorrhage.
Past Medical History:
PMH: HTN, hx TIA, CRI
PSH: IHR, lap ccy
Social History:
Retired Professor [**First Name (Titles) **] [**Last Name (Titles) 75591**]. Works around the house, recently
did some gardening. Only uses etoh socially and does not smoke.
Family History:
noncontributory
Physical Exam:
P/E at Discharge:
EXPIRED
Pertinent Results:
LABORATORIES:
Admit:
[**2175-8-19**] 09:35PM BLOOD WBC-7.8 RBC-3.94* Hgb-12.7* Hct-33.7*
MCV-86 MCH-32.1* MCHC-37.5* RDW-15.2 Plt Ct-180
[**2175-8-19**] 09:35PM BLOOD PT-13.6* PTT-20.3* INR(PT)-1.2*
[**2175-8-20**] 12:29AM BLOOD Glucose-162* UreaN-39* Creat-2.3* Na-135
K-3.6 Cl-107 HCO3-18* AnGap-14
[**2175-8-20**] 12:29AM BLOOD ALT-18 AST-30 CK(CPK)-108 AlkPhos-164*
Amylase-202* TotBili-0.6
[**2175-8-20**] 12:29AM BLOOD Albumin-3.7 Calcium-9.0 Phos-4.2 Mg-2.0
IMAGING:
CT Head [**8-19**]: 1. Stable bilateral subdural hematomas without
associated mass effect and small focus of extra-axial hemorrhage
adjacent to the left cerebellar hemisphere. 2. Bilateral
subarachnoid hemorrhages extending into sylvian fissures, which
appear slightly increased in the interval. 3. Minimally
displaced right parieto-temporal bone fracture.
MR [**Name13 (STitle) 430**] [**8-20**]: 1. Acute infarction in the right temporal and
inferior parietal lobes, in the right middle cerebral artery
territory. The right middle cerebral artery and its proximal
branches are patent, but smaller in caliber compared to the
left. This appearance is compatible with vasospasm, but onset of
vasospasm one day following subarachnoid hemorrhage is highly
unusual. 2. Bilateral subdural, subarachnoid, and
intraventricular hemorrhage, as seen on the preceding CT scan.
The parafalcine and paratentorial extent of the subdural
hemorrhage is new since [**2175-8-19**]. 3. Small right superior medial
frontal hemorrhagic contusion and a small left inferior
cerebellar hemisphere parenchymal hemorrhage, as seen on the
preceding CT scan, but newly evident since [**2175-8-19**].
TTE [**8-22**]: No cardiac source of embolus identified (cannot
definitively exclude).
TTE [**8-24**] (Bubble study): No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.
[**8-28**]: Renal U/S: neg for obstruction
EEG [**8-29**]: IMPRESSION: Abnormal EEG due to the slowing of the
background with bursts of generalized slowing, indicating a
widespread encephalopathy
and due to a lower voltage background on the right side,
indicating a
widespread cortical dysfunction on that side or material
interposed
between the brain surface and recording electrodes, e.g.
subdural fluid.
There were no clearly epileptiform features though much of the
recording
was degraded by lead artifact. An abnormal cardiac rhythm was
noted.
CT C/A/P [**9-1**]: 1. Asymmetrically enlarged right thyroid lobe
without discrete nodule, possibly due to goiter, if clinically
indicated, could be evaluated with thyroid ultrasound. 2.
Bilateral trace pleural effusions with adjacent compressive
atelectasis, cannot exclude superimposed infection in the larger
left consolidation. 3. NG tube in place. 4. Extensive
diverticulosis without diverticulitis. 5. Pagetoid bony changes.
6. Fat-containing left inguinal hernia.
MICROBIOLOGY:
[**8-19**] MRSA: neg
[**8-21**] MRSA: pending
[**8-23**] BCx: GNR's x 2 bottles
[**8-23**] UCx: NGTD
[**8-23**] UCx (anaerobic): NGTD
[**8-23**] U/A: large leuk, >182 WBC, mod bacteria, neg nitrites, few
WBC clumps
[**8-24**] BAL: 2+ GRAM POSITIVE COCCI (IN PAIRS AND CLUSTERS). 1+
GRAM POSITIVE ROD(S).
PATHOLOGY: None
Brief Hospital Course:
The patient was transferred from OSH to [**Hospital1 18**] ED having been
intubated for GCS 8. Trauma protocol was initiated on arrival
with evaluation by ACS and ED teams. Patient was
hemodynamically stable. Appropriate trauma scans were obtained
as per above. Patient was transferred to the TSICU for further
management under care of the ACS team.
Neuro: Initial CT head obtained in trauma bay demonstrated
traumatic brain injury. Dilantin loaded and maintained on
seizure prophylaxis per neurosurgery as no other NSurg
intervention was warranted. Repeat CT head [**8-20**] demonstrated
stable TBI. MRI obtained [**8-20**] demonstrated R MCA stroke.
Mental status [**8-20**] improved to support extubation though patient
patient was agitated post extubation. Agitation well managed
with medication. Neuro stroke team consulted [**8-21**]. Head CT was
repeated [**8-22**] with redistribution of traumatic bleed but overall
stable. Patient showed improved mental status and was OOB to
chair and appropriately interactive. CT head was again repeated
[**8-25**] for altered mental status and found to be largely stable.
Per neuro, EEG obtained [**2081-8-24**] to assess for occult seizure
activity though none was evident on EEG. Mental status
continued to be poor with minimal interaction [**8-30**]. Overall
activity level continued to decline. Agitation regimen was
titrated appropriately. Neurology evaluation [**9-6**] noted overall
very poor prognosis for recovery of meaningful function.
CV: Patient was hemodyamically stable on arrival. Following
diagnosis of stroke, vascular workup was undertaken including
carotid US [**8-22**] (40% stenosis bilaterally) and TTE with no
evidence of embolic source. Repeat TTE w bubble study [**8-24**] was
negative for PFO. Lopressor started [**8-25**] for persistent
tachycardia. PACS/PVCs seen on telemetry [**8-27**] though remained
hemodynamically stable. [**8-30**] demonstrated
tachycardia/hypotension in setting possible sepsis. Cardiology
consulted for paroxysmal afib in setting likely sepsis.
Amiodarone was started per cardiology. TEE performed [**9-6**]
showing preserved EF and no thrombus.
Pulmonary: Patient arrived to [**Hospital1 18**] intubated. Met criteria for
vent wean [**8-20**] and successfully extubated. Patient did well w
floor transfer [**8-23**]. Transferred back to ICU [**8-23**] PM w
respiratory distress following aspiration. Pulmonary function
worsened requiring re-intubation [**8-23**] PM with bronchoscopy
showing significant secretions. Patient extubated when meeting
criteria. Continued with labored breathing though ABGs and CXRs
without significant abnormality. Re-intubated [**8-30**] for
respiratory distress and bronchoscopy showed copious secretions.
IP consulted and repeated bronch [**9-1**] with no new findings
evident. Patient continued ventilatory support with poor
performance on CPAP.
GI/GU: On admission patient was maintained on IVF and was NPO
related to intubation. Speech and swallow evaluated patient
[**8-21**] and was cleared for supervised diet with thin liquids and
pureed solids. Fluids were discontinued [**8-22**] and patient
tolerated regular diet well. Patient was transferred to floor
[**8-23**] but likely had aspiration event with feeding. Dobhoff tube
placed [**8-24**] and TFs initiated. TFs continued with intermittent
interruptions [**1-11**] loss of enteral access. Bowel regimen was
maintained throughout admission.
Patient arrived to [**Hospital1 18**] with foley in place. Has baseline of
known CKI. Made good urine and foley removed [**8-23**] with
improvement in mental status. Diuresis with lasix initiated
[**8-22**] with good response. Finasteride and terazosin were resumed
9/14 per home regimen. Lasix gtt started [**8-28**] for fluid
overload and this had good effect. Renal US [**8-28**] for rising
creatinine showed no evidence of obstruction or renal artery
stenosis. Renal consult obtained [**8-29**]. Fluid balance managed
with albumin/lasix in combination. Recommendations from renal
followed.
ID: Patient transferred back to ICU [**8-23**] with respiratory
distress as above. Pan cultures obtained. Fever and
leukocytosis increased. UA showed likely UTI and cipro
initiated. ID was consulted [**8-24**] and patient started on
vancomycin/zosyn for presumed VAP. Febrile [**8-29**] with further
cultures obtained. ID continued to follow and antibiotics were
tailored to evolving culture data. Antibiotics discontinued
[**9-7**] as patient afebrile.
Prophylaxis: The patient received subcutaneous heparin during
this stay when cleared by neuro stroke and neurosurgery.
HEME: B/L UE swelling prompted US [**8-28**] showing B/L UE
superficial thrombophlebitis with clot surrounding RUE PICC.
PICC removed and LIJ placed. B/L LENIs were negative for DVT.
RHEUM: Concern for gout [**8-28**] prompted allopurinol therapy though
uric acid level WNL.
DISPO: Patient admitted to ICU for management. Family present
at time of arrival to [**Hospital1 18**]. Family meeting held [**8-27**] to
discuss goals of care with outcome of continued full code. In
accordance with family wishes, patient made CMO [**9-11**] in light of
poor prognosis and failure to progress.
Patient expired [**2175-9-12**].
Medications on Admission:
[**Last Name (un) 1724**]: Allopurinol 300, Atenolol 25, Desonide 0.05% top'',
Doxercalciferol 1.5, Finasteride 5, Fluticasone 50'', Furosemide
40, Hydrocortisone top 2.5%'', Ranitidine 300, Terazosin 20,
Timolol maleate (dose unknown), Triamcinolone acetonide top
0.1%'', Acetaminophen 500prn
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Right middle cerebral artery cerebrovascular accident
2. Traumatic brain injury
3. Right temporoparietal fracture
4. Aspiration pneumonia
5. Urinary tract infection
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2175-9-12**]
|
[
"403.90",
"996.74",
"584.9",
"274.9",
"434.11",
"585.3",
"276.0",
"285.9",
"041.11",
"507.0",
"427.61",
"451.82",
"801.16",
"518.81",
"995.91",
"V49.86",
"997.31",
"276.69",
"038.42",
"E884.2",
"731.0",
"599.0",
"427.31",
"276.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97",
"96.72",
"33.24",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10005, 10014
|
4337, 9629
|
269, 275
|
10226, 10236
|
1072, 4314
|
10292, 10331
|
994, 1011
|
9973, 9982
|
10035, 10205
|
9655, 9950
|
10260, 10269
|
1026, 1030
|
1044, 1053
|
200, 231
|
303, 719
|
741, 784
|
800, 978
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,118
| 111,066
|
2583
|
Discharge summary
|
report
|
Admission Date: [**2199-1-10**] Discharge Date: [**2199-1-14**]
Date of Birth: [**2128-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Abnormal ETT
Major Surgical or Invasive Procedure:
[**2199-1-10**] - CABGx3 (Left internal mammary artery->Left anterior
descending artery, Vein->Obtuse marginal, Vein->Posterior
descending artery)
History of Present Illness:
70 y/o man with peripheral vascular disease who underwent an
abnormal ETT. A recent cardiac catheterization revealed left
main and three vessel disease. He is now referred for surgical
revascularization.
Past Medical History:
CAD
HTN
Hyperlipidemia
PVD
Diabetes mellitus type 2
Prostate cancer
Social History:
Retired postal clerk. Lives with wife.
Family History:
Mother died of MI at age 54.
Physical Exam:
74 180/75 70" 225lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis. Multiple solar/actinic
kertosis and nevi. Venous stasis changes of RLE.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally
HEART: RRR, Normal S1-S2, No M/R/G
ABD: Soft, ND/NT/NABS
EXT:warm, pulses dopplerable in righ DP/PT, no bruits, right leg
with enlarged veins, mild peripheral edema
NEURO: No focal deficits.
Pertinent Results:
[**2199-1-10**] ECHO
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. The estimated right atrial pressure is
0-5 mmHg. The left ventricular cavity size is normal. There is
mild to moderate regional left ventricular systolic dysfunction
with mild anterior wall hypokinesis The remaining left
ventricular segments contract normally. Right ventricular
chamber size is normal. with borderline normal free wall
function. 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. There is no pericardial effusion.
POST CPB:
Improved biventricular systolic function.
No change in valve structure and function
[**2199-1-12**] CXR
There is no pneumothorax or appreciable pleural fluid residual
following removal of pleural tubes and tracheal extubation.
Mild-to-moderate infrahilar atelectasis in both lungs is
worsened. Heart is normal size and cardiomediastinal silhouette
is normal postoperative appearance, including small residual of
retrosternal air.
Brief Hospital Course:
Mr. [**Known lastname 13058**] was admitted to the [**Hospital1 18**] on [**2199-1-10**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. Within 24
hours, Mr. [**Known lastname 13058**] had awoke neurologically intact and was
extubated. He was then transferred to the step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. As
his blood sugars were elevated, his preoperative metformin and
avandia were resumed. Mr. [**Known lastname 13058**] continued to make steady
progress and was discharged home on postoperative day 5. He will
follow-up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 216**] as an
outpatient.
Medications on Admission:
Aspirin 81'
Lipitor 20'
Cymbalta 60'
Zetia 10'
Glipizide 10"
Metformin 1000"
Zestril 10'
Avandia 8'
Flomax 0.4'
Verapamil 240'
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. 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*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
7. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
11. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: Take for 7 days with potassium and then stop.
Disp:*5 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p CABGx3
HTN
Hyperlipidemia
PVD
Diabetes mellitus type 2
Prostate Cancer
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Take lasix 40mg once daily with potassium 20mEq for 5 days
then stop.
8) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 5003**]
Please follow-up with Dr. [**First Name (STitle) 216**] in 2 weeks.[**Telephone/Fax (1) 250**]
Please call all providers for appointments.
Completed by:[**2199-1-14**]
|
[
"V15.82",
"411.1",
"272.4",
"443.9",
"276.2",
"185",
"250.00",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5575, 5630
|
2668, 3684
|
334, 483
|
5753, 5762
|
1384, 2202
|
6578, 6935
|
879, 909
|
3861, 5552
|
5651, 5732
|
3710, 3838
|
5786, 6555
|
924, 1365
|
282, 296
|
511, 716
|
738, 807
|
823, 863
|
2212, 2645
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,016
| 105,567
|
35195
|
Discharge summary
|
report
|
Admission Date: [**2118-10-8**] Discharge Date: [**2118-10-11**]
Date of Birth: [**2070-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Jaundice
thrombocytopenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Initial history and physical is as per ICU team.
.
This is a 48 year-old male with a history of ischemic CM (EF
15%), s/p CCY 5 years ago who initially presented to [**Hospital3 25354**] with mid abdominal pain and jaundice, found to
have CBD dilated to 8mm on ultrasound. He reports that he
developed mid severe abdominal pain ("gassy") beginning after
dinner on [**10-6**]. He denies N/V/diarrhea prior to admission, but
notes few nonbloody loose stools since admission because he has
not been able to eat. He further denies chest pain, cough. He
has had no dysuria or urinary frequency. He denies change in
skin, scleral color. He does endorse diffuse pruritis. Labs on
presentation revealed t. bili of 2.5-->5, alk phos 199, ALT/AST
32/28. WBC was 11K with 5% bands and he was febrile to 102.
Subsequent CT abd/pelvis at [**Hospital3 **] showed CBD dilated to
2cm. He was started on IV unasyn and flagyl was added for c.
diff coverage given recent hospitalization and abdominal pain.
During his 2 day stay, his creatinine bumped from 1.1 on
admission to 2.7 on day of transfer. Additionally, he normally
has SBPs in the 90s, but had readings into the 70s prior to
transfer at which time he was asymptomatic.
.
He is now being transferred to [**Hospital1 18**] for ERCP out of concern for
retained stone.
.
ROS: As above. Additionally, the patient denies any fevers,
chills, weight change. His appetite has been okay. No melena,
hematochezia, chest pain, shortness of breath. +2 pillow
orthopnea, no PND. No lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash (does endorse diffuse
pruritis).
.
Past Medical History:
CAD; s/p multiple MIs ([**2112**] and [**2116**]) s/p stents
Ischemic cardiomyopathy with EF 15% and severe MR s/p ICD
s/p cholecystectomy
Hyperlipidemia
Anemia
Peptic ulcer disease
Social History:
Quit smoking approximately 5 years ago; 30+ packyear history
prior to that. Rare EtOH. No other illicits. Previously had
his own construction business, but has been on disability since
most recent MI. Recently separated from his wife.
Family History:
NC
Physical Exam:
GEN: Well-appearing older than stated age
HEENT: EOMI, PERRL, + scleral icterus, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: no bruits, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Left lung base with fine rales 1/3 up. No
wheezes/rhonchi.
ABD: +BS, soft, TTP inferior to epigastrium and just to left of
umbilicus. No rebound/guarding.
EXT: Trace edema bilaterally.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength and sensation
to soft touch no cyanosis. No ecchymoses, no petechiae. Areas
of excoriation on bilateral UEs from patient scratching.
Pertinent Results:
[**2118-10-9**] 12:45AM BLOOD WBC-7.1 RBC-4.30* Hgb-9.8* Hct-31.1*
MCV-72* MCH-22.7* MCHC-31.4 RDW-20.7* Plt Ct-9*
[**2118-10-9**] 12:45AM BLOOD Neuts-82.6* Bands-0 Lymphs-13.0*
Monos-2.6 Eos-1.6 Baso-0.2
.
[**2118-10-9**] 12:45AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-NORMAL Spheroc-1+ Ovalocy-1+
Target-1+ Schisto-1+ Burr-1+
.
[**2118-10-9**] 12:45AM BLOOD PT-19.1* PTT-36.9* INR(PT)-1.8*
.
[**2118-10-9**] 12:45AM BLOOD Glucose-83 UreaN-52* Creat-2.1* Na-129*
K-3.8 Cl-96 HCO3-20* AnGap-17
.
[**2118-10-9**] 12:45AM BLOOD ALT-13 AST-35 LD(LDH)-249 AlkPhos-105
Amylase-107* TotBili-11.5* DirBili-8.8* IndBili-2.7
.
[**2118-10-9**] 02:18AM BLOOD Ret Aut-2.8
[**2118-10-9**] 02:15AM BLOOD Fibrino-557* D-Dimer-6170*
[**2118-10-9**] 02:15AM BLOOD FDP-40-80*
[**2118-10-9**] 12:45AM BLOOD Hapto-115
.
[**2118-10-9**] 02:18AM BLOOD calTIBC-393 VitB12-1483* Folate-8.6
Ferritn-172 TRF-302
[**2118-10-9**] 02:18AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0 Iron-23*
.
[**2118-10-8**] CXR: IMPRESSION: Cardiomegaly without CHF or pneumonia.
.
[**2118-10-9**] LIVER U/S: IMPRESSION:
1. Echogenic portal triad, can be seen in the setting of
hepatitis.
2. Patent portal and hepatic veins, normal flow in the main
hepatic artery.
3. Large right pleural effusion.
4. Minimal perihepatic ascites.
5. Extra-hepatic biliary ductal dilatation, distal common duct
not visualized
due to overlying bowel gas. ERCP or MRCP can be performed if
further
evaluation is needed.
Brief Hospital Course:
48 year-old male with a history of CAD and ischemic
cardiomyopathy (EF 15%) who presented with abdominal pain and
jaundice with CBD dilatation on imaging.
.
1. Jaundice: Possible etiologies included acute hepatitis C
versus cholangitis versus choledocolithiasis. There was
evidence of CBD dilatation on OSH imaging. Interestingly
however, he wa found to be only mildly tender over RUQ rather
the majority of his discomfort is mid abdomen. No
rebound/guarding. T.bili elevation now to 11.5 (normal alk
phos). Could not perform MRCP to further evaluateas patient with
AICD. Unfortunately an ERCP could not be done because he had a
platelet count of 9 at admission. he was continued on Unasyn
while in the hospital. The patient was to be treated/worked up
further but he signed out AMA.
.
2. Thrombocytopenia: Heme/Onc was consulted for differential
including platelet clumping, DIC, TTP-HUS, medication induced.
No schistocytes were seen on smear. Unclear whether he received
SC heparin at OSH, but likely used there for prophylaxis.
Platelets at OSH were in the 250s and here, one day later, down
to 9 -> seems less c/w HIT. Heme/Onc feels this is most c/w ITP
given lack of schistocytes on peripheral smear. HITT antibody
was negative. The patient recevied was started on steroids. He
unfortunately signed out AMA before we could evaluate for a
clinical response.
.
3. ARF: Cr of 1.3 per OSH reports, but 2.1 on initial
presentation. Creatinine had risen to 2.7 but now normalized
with IVF. Concerning in the setting of his thrombocytopenia and
fever would be TTP-HUS, but appears to be pre-renal. Urine
lytes c/w this.
.
4. Hypotension: Baseline SBPs per patient run 80s-90s. Had
dipped as low as 70 systolic per OSH but patient was
assymptomatic. SBPs currently low 90s but suspect this was
related to his severe cardiomyopathy. Had previous concern for
infectious cause with fever at outside hospital but afebrile
since admit here. Responded to IVF.
.
5. Chronic systolic CHF secondary to ischemic cardiomyopathy (EF
15%): Appeared to be well compensated. The patients
antihypertensive meds and diuretics were initaially held because
of relative hypotension. [**Name2 (NI) **] will restart them as an outpatient.
.
6. CAD: Held beta blocker b/c of hypotension, held ASA for ERCP,
held statin d/t LFT abnormalities.
.
7. PUD: Given pt was on PPI as outpatient at which time
platelets were normal, this seemed to be a very unlikely cause
of the patients thrombocytopenia. PPI was continued.
.
# FEN: cardiac diet, replete lytes PRN.
.
# PPx: Venodynes.
.
# Code: FULL
.
# Dispo: The patient unfortunately signed out AMA. On the
morning he left, the patient was dressed and was about to walk
out the door when the nurse stopped him. I spent about one hour
talking to the patient trying to talk him out of signing out of
the hospital. Hr told me that he was frustrated about his whole
medical course. He was frustrated that he was transferred from
Loweell general for a procedure adn that it hasn't been done. I
explained to the pt that an ERCp could not be done because of
the risks associated with his low platelet counts and that an
MRCP could not be done because of his pacemaker. I explained to
him that his biggest problem was hi low platelet count and how
we were trying to fix it with steroids. I explained to the
patient that he would likely DIE if he left AMA. I warned him
that he was at very high risk of spontaneous bleeding, or that
his liver might fail further. I warned him that he could become
acutely anemic and induce another heart attack. Despite all my
efforts he could not be convinced to stay. The patient
expressed an understaning of his situation and is competent to
make his own medical decisions. the patient signed an AMA form
and this was placed in teh chart, I encouraged him to seek
medical attention immediately as soon as he felt ill.
Medications on Admission:
Medications on transfer:
Reglan 10mg IV q6h prn
Flagyl 500mg IV q6h
Morphine 3mg IV q2h prn
Pantoprazole 40mg IV bid
Unasyn 3g IV q6h (started [**10-6**])
ASA 325mg PO daily
Carvedilol 3.125mg [**Hospital1 **]
Digoxin 0.125 daily
Ibuprofen 600mg PO q6h prn
Simvastatin 20mg daily
Spironolactone 25mg [**Hospital1 **]
Simethicone 80mg qid
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperbiliruninemia
Hepatitis A
Thrombocytopenia
Discharge Condition:
Unstable. Patient signed out AMA
Discharge Instructions:
Patient signed out AMA
Followup Instructions:
Patient signed out AMA
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2118-10-11**]
|
[
"782.4",
"287.5",
"428.0",
"070.1",
"276.1",
"428.22",
"414.8",
"458.9",
"584.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9366, 9372
|
4721, 8632
|
342, 349
|
9464, 9500
|
3219, 4698
|
9571, 9768
|
2499, 2503
|
9020, 9343
|
9393, 9443
|
8658, 8658
|
9524, 9548
|
2518, 3200
|
277, 304
|
377, 2022
|
8683, 8997
|
2044, 2227
|
2243, 2483
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,127
| 199,271
|
11796+56288
|
Discharge summary
|
report+addendum
|
Admission Date: [**2155-12-18**] Discharge Date:
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
male with a history of Parkinson's disease contractures,
history of tracheostomies for inability to handle secretions,
history of urinary tract infection, aspiration pneumonia,
congestive heart failure and glaucoma presenting to the
MICU/SICU for evaluation for placement of [**Location (un) **] tube and
evaluation by interventional pulmonology.
The patient had a tracheostomy placed for greater than one
year. Starting in the fall he had problems that
tracheostomy, specifically problems with suctioning. The
patient apparently had difficulty in the initial placement of
the tracheostomy tube with a "actual long tube placed" and
the tube was apparently difficult to place. The patient was
unable to be suctioned in [**Month (only) 359**] and was sent to the
Operating Room after admittance for tracheostomy tube change.
It was successful. He went back to the nursing home and was
okay from that perspective until [**11-29**], when again he
could he could not be suctioned. He was taken to the
Operating Room for revision. Revision failed, however,
thoracic surgery reported a large area of necrotic tissue
with difficulty localizing the anterior wall of the trachea.
Because of that, endotracheal tube was placed on [**2155-12-4**] and the patient was placed on a T-piece at 40% FIO2.
The patient had fevers at that point at the outside hospital
and was treated for a pneumonia/bronchitis with Oxacillin and
Ceftazidime for 10 days. He had a neck computerized
tomography scan which showed "a large amount of granulation
tissue." Cardiothoracic Surgery and Otorhinolaryngology felt
they could not intervene. Based on this, the patient was
referred to the [**Hospital6 256**] for
further evaluation by Pulmonary Surgery. By report from the
outside hospital the patient had no positive micro-data and
was on no precautions.
PAST MEDICAL HISTORY:
1. Severe Parkinson's disease
2. History of tracheostomy because of inability to handle
secretions
3. History of urinary tract infections
4. History of aspiration pneumonias
5. History of decubitus ulcers
6. History of congestive heart failure
7. Glaucoma
8. Urinary retention
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Kayciel
2. Lasix 20 q.d.
3. Zantac 150 b.i.d.
4. Multivitamin one q.d.
5. Carbidopa
6. Levodopa 25/50 mg t.i.d.
7. Reglan 5 mg t.i.d.
8. Colace 100 q.d.
9. Pilocarpine 6% one drop both eyes, q.d.
10. Xalatan .005% one drop both eyes, q.h.s.
11. Jevity tube feeds 80 cc/hr and 200 cc free water boluses
b.i.d.
SOCIAL HISTORY: The patient is a retired minister.
FAMILY HISTORY: Not available.
PHYSICAL EXAMINATION: Vital signs on presentation - The
patient was afebrile with a pulse of 88, blood pressure
141/85 and saturation of 100% breathing at 22. Clinically,
generally speaking the patient was chronically ill-appearing
male, contracted. Head, eyes, ears, nose and throat,
normocephalic, atraumatic with pinpoint pupils bilaterally as
is his baseline. Dry mucous membranes. He has a
tracheostomy site that had a dry exudate. Heart, regular
rate and rhythm, no gallops, rubs or murmurs. Neck, right
internal jugular line that was clean, dry and intact, unclear
when the internal jugular line was placed. Lungs, decreased
breathsounds, right greater than left, coarse rhonchi
throughout. Abdomen, soft, gastrostomy tube in place, clean,
dry and intact, no erythema, decreased bowel sounds in th
abdomen. Extremities, no cyanosis, clubbing or edema.
Pulses 2+ dorsalis pedis and posterior tibial. Area of skin
breakdown on sacrum as well as tibia. Neurological, not
communicative. Follows simple commands, able to grip. 2+
deep tendon reflex bilaterally in upper and lower
extremities. Cranial nerves, unable to assess. The patient
with dysconjugate gaze.
LABORATORY DATA: Outside laboratory data - SMA on [**12-10**], sodium 144, potassium 4.3, chloride 108, bicarbonate 34,
BUN 23, creatinine 0.9 and glucose 199. Complete blood count
at outside laboratory, 10.5 white blood count, 31.4
hematocrit, 177 platelet count. Arterial blood gases at the
outside hospital 7.3, 8, 57, 76 on 40%. No other laboratory
data is available from the outside laboratory.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 24764**]
MEDQUIST36
D: [**2155-12-18**] 17:43
T: [**2155-12-18**] 18:50
JOB#: [**Job Number 37285**]
Name: [**Known lastname 2601**], [**Known firstname 6684**] Unit No: [**Numeric Identifier 6685**]
Admission Date: Discharge Date:
Date of Birth: Sex: M
Service:
ADDENDUM:
HOSPITAL COURSE: The patient was admitted to the MICU SICU
on the [**Hospital Ward Name 600**] of the [**Hospital1 1943**] where he continued to be on a T piece and ET tube with
plans to take him to the OR after CT surgery consult for
placement of a percutaneous tracheostomy tube. The patient
had an ABG while on the ET tube that revealed a PH of 7.41,
CO2 50 and O2 96%. Repeat on the morning of [**12-19**] was
similar. Based on this, the patient was taken to the
operating room where he had a bronchoscopy and placement of a
percutaneous trach. The patient was in the PACU on the [**Hospital Ward Name 6686**] where he was kept on SIMV and then transferred back to
medical Intensive Care Unit where he was weaned off of his
ventilator to trach mask.
DISCHARGE MEDICATIONS: KCL, Lasix 20 mg by G tube q d,
Zantac 150 mg [**Hospital1 **] by G tube, Multivitamin 5 cc by G tube,
Carbidopa Levodopa 25/250 tid, Reglan 5 mg tid, Colace 100 mg
q d, Pilocarpine 6% one drop OU qid, Xalatan .005% one drop
OU q h.s., Jevity tube feeds 80 cc by G tube, free water
boluses 200 cc H2O [**Hospital1 **].
DISCHARGE DIAGNOSES:
1. Parkinson's disease.
2. Respiratory failure.
3. Percutaneous tracheostomy tube placement.
4. Status post bronchoscopy.
PLAN: Transfer patient back to [**Hospital2 **] [**Hospital3 6687**] Hospital in
[**Hospital1 6688**].
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 2512**]
MEDQUIST36
D: [**2155-12-19**] 18:00
T: [**2155-12-19**] 19:17
JOB#: [**Job Number 6689**]
|
[
"519.1",
"428.0",
"332.0",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
2727, 2743
|
5921, 6384
|
5580, 5900
|
2335, 2657
|
4814, 5556
|
2766, 4796
|
97, 1963
|
1985, 2309
|
2674, 2710
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,590
| 184,063
|
45470
|
Discharge summary
|
report
|
Admission Date: [**2111-11-6**] Discharge Date: [**2111-11-17**]
Date of Birth: [**2056-2-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Levofloxacin / Codeine / Iodine; Iodine Containing / Oxycodone /
Hydrocodone
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Right subdural collection
Major Surgical or Invasive Procedure:
Right craniotomy for evacuation of right subdural
abscess/empyema.
History of Present Illness:
The patient is a 55-year-old male with a history of shunt and
revision in the past. About 2 to 3 months ago, the patient had a
shunt infection and the whole
shunt was removed by Dr. [**Last Name (STitle) **]. However, at that point, the
subdural collection was left intact. The patient was given
antibiotics for long-term. The patient followed up with me, and
he had a CAT scan as well as an MRI. Initially, the patient
refused the proposed surgery due to my suspicion that
this was representing an abscess. He continued with antibiotic
treatment. However, the patient started to deteriorate
neurologically, with difficulty with speech and also weakness of
the left side. An MRI showed enhancement of
that collection with what seemed to be a very thick membrane.
Then finally, the patient agreed to surgery.
Past Medical History:
-[**2109-12-13**] Cardiac Catheterization - LAD with proximal 40% and
mid
70% stenosis. Ramus with a large mid 90% stenosis was stented
with 2.5 x 23mm CYPHER DES and 3 x 13mm CYPHER DES with TIMI 3
flow. RCA was occluded in the mid segment and could not be
engaged but was filled with left-right callaterals.
-Bipolar
- NPH status post Right VP shunt in [**6-26**] and revision [**9-26**]
-Asthma
-ADHD
-High Cholesterol
-HTN
-PTSD
-AAA
- DJD
PSH: [**Name (NI) 10259**], PTCA, VP shunt [**6-26**] (Dr. [**First Name (STitle) **]/[**Hospital1 336**]), revision of VP
shunt [**9-26**] (Dr. [**Last Name (STitle) **]/[**Hospital1 18**])
Social History:
(+) cigarette smoking -quit in [**11-25**] 60ppy history, [**12-24**] ppd
on and off for 40 years
Family History:
(+) [**Name (NI) 41900**] CAD Father has CAD and CHF. Social History: Married
for 15 years with two children 10 daughter and 14 son.
Physical Exam:
From post op check
99.1 75 15 132/74
Alert and oriented x 3
Mild dysarthria
Full with all 4 extremities
No pronator drift
Eyes open spontaneously
Incision C/D/I
From POD1
Alert and attentive; awake and oriented x 3; follow commands x 4
PERRL; smile symmetric; EOMI; facial sensation intact; no drift;
tongue midline; RLE, LLE, RUE = [**4-25**] motor; LUE = Deltoid (3),
bicep (2), tricep (2), wrist (3), grip (1)
mild dysarthria, incision c/d/i; neurologically stable s/p
subdural fluid drainage
Pertinent Results:
CTH [**11-6**]
1. New right inferior frontal lobe intraparenchymal hematoma
2. Status post drainage of right frontal subdural collection
with expected postoperative changes. Right lenticular hypodense
collection has resolved. Mild amount of right subdural hematoma
remains. Left subdural hematoma is unchanged.
CTH [**11-8**]
Stable right intraparenchymal hematoma. Stable left subdural
hematoma.
Brief Hospital Course:
Patient was admitted to Neurosurgery service s/p right
craniotomy for treatment and diagnosis of a right subdural
collection which was found to be a right subdural abscess. The
patient tolerated the procedure well with an EBL of 400. For
further detail of the procedure please refer to the operative
note. He was en route back to the PACU post operatively when he
had atonic clonic seizure, loaded with dilantin and admitted to
the SICU for monitoring. On POD1, subdural JP drain was d/c'd
without complication. The POD2 CTH was stable and the patient
was transfered out of the SICU to stepdown on POD 3. ID was
consulted and managed pt with vanco and ceftaz until cultures
were back. A PICC line was placed [**1-23**] difficult access and the
initial thought that the patient would require long term abx. On
[**11-11**] abx were discontinued. The patient also developed urinary
retention on [**11-11**] and required catheterization. The patient
had complaints of left shoulder pain that was an acute
exacerbation of his chronic shoulder pain. Xrays revealed no
fracture or dislocation. Ortho was consulted and recommended
outpatient treatment of shoulder pain. Physical therapy
recommended rehab. On [**11-14**], the picc line was dislodged and
subsequent xray showed slight proximal migration of catheter
tip. Upon discharge to rehab, the patient is afebrile with all
vitals stable, tolerating po feeds, with impaired strength and
balance, and with pain controlled on po pain medication.
Medications on Admission:
ASA 325, Darvan, flomax, lisinopril, metoprolol, proventil,
spiriva, prednisone, protonix, simvastatin, diasepam, neb
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
12. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
16. Ondansetron 4 mg IV Q8H:PRN
17. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
18. HydrALAzine 10 mg IV Q6H:PRN SBP>140
19. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
20. Insulin Lispro 100 unit/mL Solution Sig: One (1) Units per
sliding scale Subcutaneous ASDIR (AS DIRECTED): As directed per
sliding scale.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Right subdural empyema with central necrosis.
Discharge Condition:
Stable
Discharge Instructions:
??????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:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) 739**] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
|
[
"314.01",
"309.81",
"401.9",
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"324.0",
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"V58.65",
"780.39",
"414.01",
"996.63",
"441.4",
"296.80",
"788.20",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.31",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
6720, 6787
|
3158, 4662
|
367, 436
|
6877, 6886
|
2734, 3135
|
8205, 8483
|
2064, 2118
|
4830, 6697
|
6808, 6856
|
4688, 4807
|
6910, 8182
|
2214, 2715
|
302, 329
|
464, 1273
|
1295, 1932
|
2134, 2199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,906
| 103,986
|
50181
|
Discharge summary
|
report
|
Admission Date: [**2178-10-1**] Discharge Date: [**2178-10-12**]
Date of Birth: [**2126-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Mechanical ventilation
PICC line placement
Left Femoral Central line, placed and removed
Right Arterial line
History of Present Illness:
Mr. [**Known lastname **] is a 51 year-old man with a history of chronic
hypercapneic respiratory failure s/p trach, COPD, and morbid
obesity who presented from [**Hospital 100**] Rehab with hypotension and is
admitted to the MICU for further management.
He was trached on [**2178-8-13**] and last discharged on [**2178-9-18**] for
hypercapneic respiratory failure which was thought to be
secondary to a cuff leak, though he was also treated for
resistant psuedomonas VAP during this admission. He went to
[**Hospital 100**] rehab and completed a course of tobramycin (last dose
?[**2178-9-19**]). He also had blood cx that grew coag negative staph
and was started on vanc on [**9-27**]. He had a leukocytosis, with a
WBC count of 16 that trended down to 6 on the day of admission.
A urine cx grew ESBL klebsiella on [**9-30**] but he was not started
on antibiotics for this for unclear reasons. During this time,
his metoprolol was also increased from 12.5 mg po tid to 25 mg
po tid on [**9-27**] for improved a. fib heart rate control.
On the day of admission, he was found to have a BP of 85/65 ->
60/palp from a baseline in the low 100s systolic after
debridement of a right flank wound. He was thought to be
bacteremic and given approximately 1L IVF bolus with no
response. He was then transferred to [**Hospital1 18**] for further
management.
On arrival, VS were 97.8 84 80/47 24 100% on unknown vent
settings. He was thought to be septic vs having beta blocker
toxicity (last metoprolol given at 2 p.m.) and was given zosyn,
1.5 L IVF, and glucagon, with improvement in SBP to 120
transiently after the glucagon. Toxicology was consulted and
felt that beta blocker toxicity was unlikely given absence of
bradycardia.
A right radial a-line and left femoral line were placed for
access. A CXR was performed and demonstrated infiltrate vs
overload. IVFs were held after the CXR, and he was started on
levophed. Per report, a bedside ECHO was also performed to eval
for tamponade but was limited secondary to body habitus.
On the floor, he was minimally responsive to verbal stimuli and
began having rhythmic, tooth clattering motions at the chin. He
was given 1 mg IV ativan x 2 with resolution.
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:
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 a motorized chair for most of his mobility.
Family History:
Noncontributory
Physical Exam:
Vitals: 97.8 84 80/47 24 100% FIO2 50%
General: morbidly obese, trached and vented, responds to verbal
stimuli, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, gazing to the
left
Neck: supple, JVP unable to assess, no LAD
Lungs: bilateral rhonchi, no rales or wheezes
CV: distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, distended, bowel sounds present, no organomegaly
GU: purulent discharge around foley.
Ext: warm, well perfused, 2+ pulses, 1+ LE edema, erythematous
patches scattered across chest, arms, and legs.
Pertinent Results:
Admission Notes;
[**2178-10-1**] 05:59PM HGB-9.7* calcHCT-29 O2 SAT-89 CARBOXYHB-1 MET
HGB-0.1
[**2178-10-1**] 05:59PM GLUCOSE-104 LACTATE-1.0 NA+-140 K+-5.1
CL--99*
[**2178-10-1**] 05:59PM TYPE-ART RATES-/30 TIDAL VOL-500 O2-50
PO2-50* PCO2-81* PH-7.27* TOTAL CO2-39* BASE XS-6 -ASSIST/CON
INTUBATED-INTUBATED
[**2178-10-1**] 06:10PM URINE RBC-0-2 WBC-[**4-9**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2178-10-1**] 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2178-10-1**] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2178-10-1**] 06:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2178-10-1**] 06:10PM URINE HOURS-RANDOM
[**2178-10-1**] 06:40PM FIBRINOGE-593*
[**2178-10-1**] 06:40PM PLT SMR-NORMAL PLT COUNT-229
[**2178-10-1**] 06:40PM PT-13.7* PTT-35.1* INR(PT)-1.2*
[**2178-10-1**] 06:40PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
STIPPLED-OCCASIONAL
[**2178-10-1**] 06:40PM NEUTS-69 BANDS-2 LYMPHS-10* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-5* NUC RBCS-2*
[**2178-10-1**] 06:40PM WBC-10.5 RBC-3.25* HGB-8.4* HCT-29.7* MCV-91
MCH-26.0* MCHC-28.5* RDW-19.0*
[**2178-10-1**] 06:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2178-10-1**] 06:40PM proBNP-[**Numeric Identifier 21797**]*
[**2178-10-1**] 06:40PM LIPASE-17
[**2178-10-7**] LE Dopplers:
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of bilateral
common femoral, superficial femoral, popliteal and tibial veins
were performed. Note is made that the study is limited by the
patient's body habitus. There is normal low, compression, and
augmentation seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in either leg.
[**2178-10-7**] ECHO:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**2178-10-2**] CT Head
FINDINGS: There is no intracranial hemorrhage, edema, mass
effect, or
vascular territorial infarction. The ventricles and sulci are
normal in size and in configuration. Included osseous structures
are unremarkable, and the visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
[**2178-10-2**] CT CHEST:
Findings: There has seen no interval change in diffuse
paraseptal and
centrilobular emphysematous changes of the lungs which
predominantly affect the apices. Diffuse fibrotic interstitial
abnormality evidenced by
bronchiectasis, bronchiolectasis, ground-glass opacities and
honeycombing
appears unchanged. There is new focus of consolidation within
the left lower lobe. Elevated left hemidiaphragm is unchanged.
No central pathologically enlarged nodes are visualized. No
pleural or
pericardial effusion is seen. The visualized part of the upper
abdomen
including adrenal glands, superior pole of the kidneys, liver,
and spleen
appear unremarkable. Gastrostomy tube is in place.
Ultrasound LEs
CONCLUSION: No evidence of deep vein thrombosis.
KUB
FINDINGS: A gastric tube is visualized. There is a paucity of
gas is seen in the abdomen. Supine films only were obtained and
therefore I cannot assess for any air-fluid levels.
Micro-
[**2178-10-5**] 10:28 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2178-10-12**]**
GRAM STAIN (Final [**2178-10-5**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2178-10-12**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA. 3RD TYPE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 16 I
CEFTAZIDIME----------- 16 I 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 2 S 2 S
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- =>128 R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 year-old man with a history of chronic
hypercapnic respiratory failure s/p trach, COPD and Cor
Pulmonale, and morbid obesity who presented from [**Hospital 100**] Rehab
with hypotension and was admitted to the MICU for further
management
# Hypotension/Sepsis: Acute hypotension was likely related to
sepsis given coag neg staph in blood cultures and ESBL
klebsiella in urine culture, which was not yet treated at Rehab.
Pneumonia was also thought to be a source of infection. There
was some initial concern for beta blocker toxicity but this
seemed unlikely considering that patient was stable regimen for
three days and was not bradycardic on presentation. Chest CT
showed extensive interstitial lung disease with end stage
emphysema change. Pt was cultured and sputum showed growth first
of proteus and later MDR pseudomonas. Also, pt had a large flank
ulcer on the right side with drainage, with GNRs. Surgery
evaluated wound, but pt did not appear to have any pockets of
infection and was to unstable for more exploration. IVF were
given initially. Later pressors were needed to sustain SBP>110.
Echo showed worsening cor pulmonale. Pt was started on vanco and
meropenum. Later change to [**Female First Name (un) **] and vancomycin level was
supratherapeutics after the third dose throughout his
hospitalization. He required increasing amounts of vasopressors-
Levophed, vasopressin, and then on day of expiation was also on
Neo-Synephrine and tried briefly on dobutamine without
improvement in BP.
# Hypoxic/Hypercapnic respiratory failure: Multifactorial
respiratory failure secondary to obstructive COPD and
restrictive lung disease and obesity hypoventilation, s/p
tracheostomy on [**2178-8-13**]. Also had worsening cor pulmonary from
lund disease. As stated about was treated for sepsis including
pneumonia. Became difficult to ventilate and PCO2 continued to
rise despite increased ventilator settings. PCO2 rose to >100
and pt was paralyzed. Pt was continued on albuterol and
ipratropium bronchodilators. Diuresis was attempted later in his
course without significant improvement. Esophageal balloon was
placed to optimized his PEEP. As stated above he was treated
with tobramycin for his PNA. For his acidosis, as his pH fell
below 7.2, he was treated with bicarb gtt and boluses.
# Altered mental status: Was gazing to the right and had
rhythmic movements of chin/teeth clattering concerning for
seizure versus clattering from hypothermia vs electrolyte
abnormality on admission. This appeared to respond to Ativan.
Per [**Hospital 100**] rehab, usually responsive to name and does
occasionally have right [**Hospital1 **] gaze. Before paralysis pt was
responsive to simple questions with nodding/shaking of the head.
EEG was ordered to evaluate for seizure activity.
# Rash with erythematous patches: concerning for urticaria
though had received beta-lactams before without reaction.
Improved with Benadryl. Did not reoccur
# Chronic kidney injury: Cr of 1.3 was improved from creatinine
at last discharge of 2 and has had elevated Cr during recent
hospitalizations. Cr baseline was 0.6 in [**2178-8-5**]. History of
AIN. Renally dosed his medications.
# Atrial fibrillation: Was on metoprolol at rehab for rate
control, not on warfarin secondary to history of RP bleed. Held
his metoprolol due to hypotension.
On the morning of [**2178-10-12**], pt became steadily more hypoxic with
sats in the 70s despite maximizing vent settings. BP dropped
lower and pt required 3 pressors. ABG showed increasing
acidosis. Bicarb x 5 amps was given. Atropine and Epi were given
as pt became more bradycardic and then asystolic. CPR was
started and was not success in regaining a cardiac rhythm. Time
of death was 11:47. Attending called the family as these events
occurred, family arrived at bedside after pt had expired. No
autopsy was requested.
Medications on Admission:
Vancomycin - renally dosed ([**9-27**])
Lactulose 30 mL NG Q8H:PRN bm
Fentanyl Patch 100 mcg/hr TP Q72H
Clonazepam 1 mg NG [**Hospital1 **]
Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
Lidocaine 5% Patch 1 PTCH TD DAILY 12 hrs on, 12 hrs off
Magnesium Oxide 400 mg DAILY THROUGH GTUBE
Omeprazole 40 mg NG DAILY
Lorazepam 1 mg IV Q4H:PRN anxiety
Polyethylene Glycol 17 g PO DAILY:PRN
Albuterol Inhaler [**3-11**] PUFF IH Q4H:PRN dyspnea
Ipratropium Bromide MDI [**3-13**] PUFF IH QID
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Insulin SC (per Insulin Flowsheet) Sliding Scale
Heparin 5000u sc tid
Metoprolol tartrate 25 mg tid
Hydromorphone 5 mg q6h prn per gtube
Lorazepam 1 mg q2h IV prn
Morphine 4 mg q4h SL prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2178-10-12**]
|
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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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328, 438
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13933, 13942
|
3967, 9123
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13966, 13975
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3354, 3948
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277, 290
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466, 2673
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11503, 13041
|
2695, 3091
|
3107, 3306
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,538
| 175,188
|
42872
|
Discharge summary
|
report
|
Admission Date: [**2105-6-15**] Discharge Date: [**2105-6-23**]
Date of Birth: [**2049-4-29**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left cranial defect
Major Surgical or Invasive Procedure:
[**2105-6-15**] Left cranioplasty
[**2105-6-15**] Left craniotomy evacuation of epidural hematoma
History of Present Illness:
This is a 50 year old man with a history of HTN, polysubstance
abuse (cocaine,
heroin, alcohol), hepC presented recently to [**Hospital 487**] Hospital
with headache and ?fall to head. We saw him [**2105-2-19**].
AT THAT TIME GCS on arrival was 11 and patient found to have
Right sided hemiplegia. NCHCT done at that time revealed large L
basal ganglia bleed with minimal midline shift. Pt found to
deteriorate from there with subsequent intubation on propofol.
We took him to the OR [**2-19**] for a L hemicraniectomy for
decompression. He resides at rehab right now and has much
improved since.
Past Medical History:
- polysubstance abuse
- HTN
- Hep C
- HIV, CD4 510 in [**2105-5-18**]
- IVC filter
- ICH, s/p hemicraniectomy [**2105-2-19**]
- Laparotomy [**2-/2105**] for acute abdomen during G tube placement
- Syphilis 20 years ago
- Latent TB 10 years ago, treated with INH for one year
Social History:
From OMR:
He is originally from [**State 3908**], he moved to Mass in [**2102**] after
being inmate x 15 years in [**State 3908**]. He was living in shelters
until his ICH and since then has been at [**Hospital3 **].
[**Last Name (un) **] history of substance abuse including Heroin, cocaine,
opioids, alcohol, and intermittent tobacco smoking.
Family History:
From OMR: No history of neoplastic/infectious diseases
Physical Exam:
On Admission:
AF VSS
normocephalic, R indentation from flap removal
HEENT: no LNN
Pupils: PERL
Neck: Supple.
Lungs: no SOB, CTA bilaterally.
Cardiac: RRR
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: cooperates well with exam.
Orientation: x 3 (aphasic)?
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2-->1 on R and
3-->2 on left. Visual fields not assessed
V, VI: intact doll's eyes
VII: IX, X: Palatal elevation symmetrical.
Motor: dense central R hemiparesis
Sensation: perceives pain and LT on the R; left nl
Reflexes: B T Br Pa Ac
Right 3+ ------------->
Left 2+ ------------->
Toes upgoing on right
Clonus 5 B on R
Coordination: n/a
At discharge:
awake, alert, oriented x [**1-23**]. Speaks in short phases. Follows
simple commands. Pupils asymmetric, L > R, both reactive. Right
hemiparesis. Moves left spontaneously.
Pertinent Results:
[**2105-6-15**] Ct head - Status post left cranioplasty with large left
extraaxial hematoma with pneumocephalus. This results in partial
effacement of the left lateral and third ventricles, and 8 mm
rightward shift of normally midline structures.
[**6-15**] CT head - Interval evacuation of left extraaxial hematoma,
which is now largely replaced with air and a small amount of
residual fluid. Persistent mass effect with 8 mm rightward
shift of normally midline structures. Effacement of the third
and left lateral ventricles, without evidence of right lateral
ventricle entrapment.
[**6-16**] CT head:
IMPRESSION:
1. Very slight decrease in the amount of postoperative
pneumocephalus and
mass effect.
2. Small amount of stable residual subdural blood products in
the surgical bed.
3. No evidence of new hemorrhage.
[**2105-6-16**] NCHCT:
IMPRESSION:
1. No change in the appearance of the intracranial
postoperative
pneumocephalus and small amount of left subdural blood products.
Stable
intracranial mass effect.
2. Increase in the amount of fluid in the subgaleal space
overlying the left cranioplasty with a decrease in the amount of
subcutaneous emphysema.
Brief Hospital Course:
Patient was admitted to Neurosurgery on [**2105-6-15**] and underwent
the above stated procedure. Please review dictated operative
report for details. Patient was extubated without incident and
transferred to PACU then floor in stable condition. Patient
developed increasing subgaleal swelling and increasing
headaches. A repeat Ct head showed a large left Epidural
hematoma. He was take emergently back to the OR for a craniotomy
and evacuation of EDH. he tolerated this procedure well. He
remained intubated and transferred to SICU. He was extubated
without incident on [**6-16**]. He was then transferred to the floor
in stable condition. CT head done on [**6-16**] showed pneumocephalus
and 100% oxygen was intiated. He became for confused with a
tense craniotomy site in the afternoon. CT head was without much
changes, no acute hemorrhage. He was started on both Dilantin
and levetiracetam. He was more alert and oriented on [**6-17**] and he
was transfered to the SDU. SQH was started.
He was transferred out of the SDU on [**6-18**] and was ready for
discharge, awaiting guardianship [**Name2 (NI) 92579**]. On [**6-19**] he was
tolerating his tube feeds at goal. Patient was febrile
overnight on [**6-19**] to 102. An infectious work-up was sent
including CBC, urine cultures, blood cultures, and CXR. CBC
revealed a WBC of 13.3. Blood cultures, urine cultures, and CXR
were negative. A medicine consult was obtained. On [**6-21**], his WBC
was elevated, CBC with diff was sent. Urine culture showed
E.coli and he was started on IV ceftriaxone to complete 10-day
course (first day [**2105-6-21**], last day [**2105-6-30**]). He was screened for
rehab and accepted pending approval of his HCP. On [**6-22**], his HCP
was [**Name (NI) 653**] and agreed to his placement. He will be discharged
to rehab on [**6-23**].
===============================
TRANSITION OF CARE:
-Patient has a chronic microcytic anemia documented throughout
hospitalization; HCT stable between 24-28.
-Pt needs to complete 10-day course of ceftriaxone for resistant
UTI. If cannot receive IV ceftriaxone at rehab, should switch to
PO cefpodoxime (last day [**2105-6-30**]).
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
hold for sbp <100
2. Baclofen 5 mg PO BID
Hold for change in mental status, sedation
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Calcium Carbonate 750 mg PO TID
5. Citalopram 20 mg PO DAILY
6. Cyclobenzaprine 5 mg PO TID:PRN Muscle spasm
Hold for sedation, RR <10, change in mental status
7. Docusate Sodium 100 mg PO BID
8. HydrALAzine 50 mg PO BID
hold for sbp <100
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheeze
10. Lisinopril 40 mg PO DAILY
hold for sbp <100
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
hold for sedation, RR <10, change in mental status
14. Sucralfate 1 gm PO QID
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Amlodipine 10 mg PO DAILY
3. Baclofen 5 mg PO Q12H
4. Bisacodyl 10 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
7. Docusate Sodium 100 mg PO BID
8. LeVETiracetam 500 mg PO BID
9. Lisinopril 40 mg PO DAILY
10. Metoclopramide 10 mg PO TID
11. Multivitamins 1 TAB PO DAILY
12. Phenytoin (Suspension) 100 mg PO Q8H
13. Sucralfate 1 gm PO QID
14. Senna 1 TAB PO BID
15. HydrALAzine 50 mg PO BID
16. Heparin 5000 UNIT SC TID
17. Calcium Carbonate 750 mg PO TID
18. Famotidine 20 mg PO BID
19. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
left cranial defect
left epidural hematoma
cerebral edema
mental status change
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Have a caretaker 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.
?????? Your wound was closed with staples. You must wait until after
they are removed to wash your hair. You may shower before this
time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? You have been prescribed Keppra (Levetiracetam) and Dilantin
(Phenytoin) for anti-seizure medicine, please take it as
prescribed and follow up with laboratory blood drawing for
phenytoin level in one week. This can be drawn at your extended
care facility or your PCP??????s office, but please have the results
faxed to [**Telephone/Fax (1) 87**].
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 [**6-30**] days(from your date of
surgery) for removal of your staples and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in [**3-27**] weeks.
??????You will need a CT scan of the brain without contrast.
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15,232
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52431+52432+52433
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Discharge summary
|
report+report+report
|
Admission Date: [**2182-12-11**] Discharge Date: [**2183-1-27**]
Service: VASCULAR SURGERY
CHIEF COMPLAINT:
Bilateral necrotic toe ulcers.
HISTORY OF PRESENT ILLNESS: The patient is a 77 year old
gentleman with end-stage renal disease and hemodialysis and
severe peripheral vascular disease, status post multiple
previous bypass procedures for his lower extremities, who
presented on the [**10-11**] with multiple bilateral
ulcers on his toes which had been present since the [**Month (only) 205**] of
the previous years. They had been treated conservatively
without success. The ulcers had grown coagulase negative
Staphylococcus and Gram negative rods for which he was on
p.o. antibiotic treatment.
PAST MEDICAL HISTORY:
1. Non-insulin dependent diabetes mellitus.
2. Hypercholesterolemia.
3. Hypertension.
4. Severe peripheral vascular disease.
5. Stable pulmonary nodule.
6. Glaucoma.
7. Atrial fibrillation.
8. Chronic obstructive pulmonary disease.
9. L4-5 stenosis.
PAST SURGICAL HISTORY:
1. Status post L4-5 decompressive laminectomy.
2. Status post right femoral PT bypass procedure in [**2172**].
3. Status post right toe amputation.
4. Status post revision left femoral PT bypass.
5. Status post left carotid endarterectomy in [**2173**].
6. Status post appendectomy.
MEDICATIONS ON ADMISSION:
1. Insulin sliding scale.
2. Xalatan eye drops.
3. Neurontin.
4. Prandin.
5. Ambien.
6. Lipitor.
7. Nephrocaps.
8. Prozac.
9. PhosLo.
10. Zantac.
PHYSICAL EXAMINATION: On admission, the patient was afebrile
with stable vital signs. He was alert, oriented times three.
Lungs are clear to auscultation. He had a normal sinus
rhythm. Abdomen was soft, nontender, nondistended.
Extremity examination revealed multiple necrotic dry ulcers
on the right foot, involving the great toe and the lateral
three toes as well as the medial and lateral aspect of the
foot. There was no associated cellulitis or pus. On the
left foot, there was a Grade II ulcer with granulation tissue
on the base. The third toe also had a necrotic ulcer down to
the base. Peripheral pulse examination reveals a palpable
femoral and popliteal pulse on the left, Doppler signals on
the left dorsalis pedis and posterior tibial. On the right,
he had palpable femoral pulses and Doppler-able dorsalis
pedis and posterior tibial signals.
He was admitted with a plan for a left TMA and a right below
the knee amputation after appropriate preoperative work-up.
SUMMARY OF HOSPITAL COURSE: The patient was placed on
Ciprofloxacin and underwent preoperative work-up which
included an EKG, type and screen, and chest x-ray. He
underwent a left TMA and a right below the knee amputation on
the [**10-13**]. Postoperatively he was stable and
transferred to the floor and did well on postoperative day
one.
On postoperative day two, that is on the [**10-15**], he
was found to be somewhat sleepy, and his O2 saturations were
on the low side. Aspiration pneumonia was presumed since the
patient had a strong history of previous aspiration causing
aspiration pneumonitis. He was put on Vancomycin and Flagyl
antibiotics. Later that day, he was found to be more
somnolent with low O2 saturations. He was transferred to
VICU to be managed in a more monitored set-up. He had an
A-line inserted and left subclavian vein Cordis inserted.
Later that day, he had further deterioration in his mental
status. He underwent a CT scan of his head which was
negative for any hemorrhage or infarction. A Swan-Ganz
catheter was floated and the patient was intubated and
transferred to the Intensive Care Unit. A chest x-ray
revealed a retrocardiac density further confirming the
clinical suspicion of aspiration pneumonitis as the cause of
his clinical deterioration. He was started on Ceftriaxone,
Vancomycin and Flagyl.
The patient had a prolonged course in the Intensive Care
Unit. He continued to have temperature spikes initially and
was cultured multiple times. On the [**10-18**], he had
an A-line change and he was pan cultured. He also underwent
a bronchoscopy which revealed a lot of secretions in both
left and right tracheal branches. The left subclavian Swan
was changed to a triple lumen central venous line. On the
[**10-20**], he had a further temperature spike with rise
in white blood cell count and was re-cultured. He continued
to be on antibiotic coverage.
His initial sputum cultures grew yeast. Later sputum and
blood cultures grew Gram negative rods. He has further
temperature spikes on the 13th and [**10-23**] for which
he was cultured. On the [**10-23**] he was weaned from
his vent settings and was extubated, however, his respiratory
status rapidly deteriorated and he required to be
re-intubated within a few hours. He was bronchoscoped on the
14th after intubation and a lot of secretions were suctioned
out. He underwent a change of his left subclavian over wire
and the tip was sent for culture.
The patient then remained intubated for a prolonged period
with a failure to wean successfully. During his Intensive
Care Unit course, the patient was intermittently hypotensive
requiring Neo-synephrine or Levo-pressor support. The
hypotensive periods were usually coincided with his
hemodialysis sessions.
On the [**11-1**], the patient underwent a tracheostomy.
This was a percutaneous tracheostomy done without any
complications.
The patient seemed to be more withdrawn with worsening in
mental status. He underwent an MRI of his brain which was
essentially normal and did not reveal any infarction.
During the initial phase of his Intensive Care Unit stay, his
left TMA and right below the knee amputation wounds were
stable in appearance. However, towards the end of [**Month (only) 404**] it
was noted that there was a breakdown at the suture line of
the left TMA without evidence of cellulitis or any pus or
infection. On the right below the knee amputation the suture
line had broken down in a couple of places. Stumps were
dressed with wet-to-dry normal saline dressing changes three
times a day.
Neurology consult was sought for his mental status changes
and he underwent an lumbar puncture in addition to the
previously
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2183-1-24**] 11:40
T: [**2183-1-27**] 15:41
JOB#: [**Job Number **]
Admission Date: [**2182-12-11**] Discharge Date: [**2183-1-27**]
Service: Vascular Surgery
CHIEF COMPLAINT: Two bilateral necrotic ulcers.
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
gentleman with end-stage renal disease (on hemodialysis), and
sever peripheral vascular disease, status post multiple
previous bypass procedures for his lower extremities who
presented on [**12-11**] with multiple bilateral ulcers on his
toes which have been present since [**Month (only) 205**] of the previous year.
They had been treated conservatively without success. Ulcers
had grown coagulase-negative Staphylococcus and gram-negative
rods, for which he was on p.o. antibiotic treatment.
PAST MEDICAL HISTORY:
1. Non-insulin-dependent diabetes mellitus.
2. Hypercholesterolemia.
3. Hypertension.
4. Severe peripheral vascular disease.
5. Stable pulmonary nodule.
6. Glaucoma.
7. Atrial fibrillation.
8. Chronic obstructive pulmonary disease.
9. L4-L5 stenosis.
PAST SURGICAL HISTORY:
1. Status post L4-L5 decompressive laminectomy.
2. Status post right femoral posterior tibialis bypass
procedure in [**2172**].
3. Status post right toe amputation.
4. Status post revision left femoral posterior tibialis
bypass.
5. Status post left carotid endarterectomy in [**2173**].
6. Status post appendectomy.
MEDICATIONS ON ADMISSION: Insulin sliding-scale, Xalatan
eyedrops, Neurontin, Prandin, Ambien, Lipitor, Nephrocaps,
Prozac, Phos-Lo, Zantac.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient was afebrile was stable vital signs. He was alert
and oriented times three. Lungs were clear to auscultation.
He had a normal sinus rhythm. The abdomen was soft,
nontender, and nondistended. Extremity examination revealed
multiple necrotic dry ulcers on the right foot involving the
great toe and lateral three toes as well as the medial and
lateral aspect of the foot. There was no associated
cellulitis or pus. On the left foot, there was a great toe
ulcer with granulation tissue at the base. The third toe
also had a necrotic ulcer down to the base. Peripheral pulse
examination revealed palpable pulse on the left, palpable
femoral and posterior tibialis pulses on the left. Doppler
signal on the left, dorsalis pedis and posterior tibialis.
On the right, he had palpable femoral pulse and dopplerable
dorsalis pedis and posterior tibialis signals.
HOSPITAL COURSE: He was admitted with a plan for a left
transmetatarsal amputation and a right below-knee amputation
after appropriate preoperative workup.
The patient was placed on ciprofloxacin and underwent
preoperative workup which included an electrocardiogram, type
and screen, and chest x-ray. He underwent a left
transmetatarsal amputation and a right below-knee amputation
on [**12-13**].
Postoperatively, he was stable and transferred to the floor
and did well on postoperative day one. On postoperative day
two, [**12-15**], he was found to be somewhat sleepy, and his
oxygen saturations were on the low side. Aspiration
pneumonia was presumed as the patient had a strong history of
previous aspiration causing aspiration pneumonitis. He was
placed on vancomycin and Flagyl antibiotics. Later that day,
he was found to be more somnolent with low oxygen
saturations. He was transferred to the Vascular Intensive
Care Unit to be managed in a more monitored setting. He had
an A-line inserted and left subclavian vein cordis inserted.
Later that day, he had further deterioration in his mental
status. He underwent a CT scan of his head which was
negative for any hemorrhage or infarct. A Swan-Ganz catheter
was floated, and the patient was intubated and transferred to
the Intensive Care Unit. A chest x-ray revealed a
retrocardiac density, further confirming the clinical
suspicion of aspiration pneumonitis as the cause of his
clinical deterioration. He was started on ceftriaxone,
vancomycin, and Flagyl.
The patient had a prolonged course in the Intensive Care
Unit. He continued to have temperature spikes initially and
was cultured multiple times. On [**12-18**], he had an A-line
change and he was pan cultured. He also underwent a
bronchoscopy which revealed a lot of secretions in both the
left and right tracheal branches. The left subclavian
Swan-Ganz catheter was changed to a triple lumen central
venous line.
On [**12-20**], he had a further temperature spike with a rise
in white blood cell count. He was recultured. He continued
to be on antibiotic coverage. His initial sputum cultures
grew yeast. Later sputum and bronchoalveolar lavage cultures
grew gram-negative rods. He had further temperature spikes
on [**12-22**] and [**12-23**] for which he was cultured. On
[**12-23**], he was weaned from his ventilator settings and
was extubated. However, his respiratory status rapidly
deteriorated and he required reintubation within a few hours.
He received bronchoscopy on [**12-23**] after intubation, and
a lot of secretions were suctioned out. He underwent a
change of his left subclavian central venous line over wire
and the tip was sent for cultures. The patient then remained
intubated for a prolonged period with failure to wean
successfully.
During his Intensive Care Unit course, the patient was
intermittently hypotensive requiring Neo-Synephrine or
Levophed pressor support. The hypotensive periods usually
coincided with his hemodialysis sessions.
On [**1-1**], the patient underwent a tracheostomy. This
was a percutaneous tracheostomy done without any
complications.
The patient seemed to be more withdrawn with worsening mental
status. He underwent a magnetic resonance imaging of his
brain which was essentially normal. It did not reveal any
infarct.
During the initial phase of his Intensive Care Unit stay, his
left transmetatarsal amputation and right below-knee
amputation wounds were stable in appearance. However, toward
the end of [**Month (only) 404**] it was noted that there was a breakdown at
the suture line of the left transmetatarsal amputation
without evidence of cellulitis or any pus or infection. On
the right below-knee amputation, the suture line had broken
down in just a couple of places. These stumps were dressed
with wet-to-dry normal saline dressing changes t.i.d.
A Neurology consultation was sought for his mental status
changes, and he underwent an lumbar puncture in addition to
the previously mentioned magnetic resonance imaging. The
lumbar puncture was essentially negative.
Mr. [**Known lastname 108342**] had another temperature spike on [**1-11**], for
which he was recultured, and vancomycin was added to his
antibiotic coverage to broaden the spectrum. He underwent a
repeat bronchoscopy on [**1-12**]. In view of his altered
mental status and his intermittent hypotension requiring
pressor support, the possibility of adrenal insufficiency was
entertained, and an Endocrinology consultation was sought. A
culture insemination test was performed, and the test
confirmed the possibility of adrenal insufficiency. He was
therefore started on hydrocortisone at 50 mg t.i.d. with a
subsequent taper.
On [**1-18**], the left transmetatarsal amputation and right
below-knee amputation wound appearances began to
progressively deteriorate. The left transmetatarsal
amputation was necrotic with the wound having broken down and
the bone exposed. The right below-knee amputation also had
breakdown at the suture line with no evidence of any healing.
On [**1-19**], it was noted that there were further necrotic
patches more proximally on the left knee, on the lateral
aspect of the left leg, and also on the medial side of the
left leg. These were felt to be secondary to pressure from
the knee immobilizer which was then discontinued.
At this stage, Dr. [**Last Name (STitle) 1476**] had an extensive discussion with
Mr. [**Known lastname 108343**] family. Dr. [**Last Name (STitle) 1476**] felt that from a
peripheral vascular disease standpoint, his left lower
extremity graft had failed, with a necrotic left
transmetatarsal amputation, with further patches of necrosis
proximally, as well as a nonhealing right below-knee
amputation stump. This warranted bilateral above-knee
amputations if any healing was to be achieved in the lower
extremity wounds. Overall, the patient was not progressing
well and was ventilator dependent, hemodialysis dependent,
with added adrenal insufficiency. The family decided to
progress aggressively with all attempts to manage the
patient. They agreed to have a bilateral above-knee
amputations to salvage the limbs.
On [**1-23**], he underwent bilateral above-knee
amputations. The procedure was uneventful, and the patient
remained stable. After starting the hydrocortisone, the
patient's mental status had improved slightly. He seemed to
be a little more alert and aware of his surroundings. He
also was no longer pressor dependent and did not have any
periods of hypotension during his hemodialysis.
At the time of this dictation, the patient remained afebrile
with stable vital signs. He ventilator settings have weaned
down to a pressure support of 10, positive end-expiratory
pressure of 7.5, and 50% FIO2. At these settings he draws
tidal volumes of around 500 cc. He had coarse bilateral
breath sounds. His abdominal examination was soft,
nondistended, and nontender. His bilateral above-knee
amputation stumps had clean, dry, and intact dressings.
CONDITION AT DISCHARGE: Mr. [**Known lastname 108342**] is a 77-year-old
diabetic gentleman with end-stage renal disease, on
hemodialysis, several peripheral vascular disease, who is
status post failed bypass graft, failed conservative
amputation, now with bilateral above-knee amputations. He
had a tracheostomy and is currently ventilator dependent. He
is currently tolerating enteral feedings via a jejunostomy
tube. He is hemodynamically stable. He is currently
completing a course of ceftriaxone for his pneumonia. The
last sputum cultures have grown out Enterobacter cloacae. He
is also on a steroid taper for his adrenal insufficiency.
DISCHARGE DIAGNOSES:
1. Severe peripheral vascular disease.
2. Status post bilateral above-knee amputation.
3. Adrenal insufficiency, on a steroid taper; altered mental
status secondary to adrenal insufficiency as well as
prolonged intubation and Intensive Care Unit course.
4. Respiratory failure secondary to aspiration pneumonia;
failed extubation, status post percutaneous tracheostomy and
ventilator dependent.
5. End-stage renal disease, on hemodialysis.
6. Non-insulin-dependent diabetes mellitus.
DISCHARGE DISPOSITION: The patient is status post
tracheostomy and ventilator dependent. He was to go to
ventilatory rehabilitation. He is currently fed by his
percutaneous jejunostomy tube. He needs physical therapy for
his bilateral above-knee amputations.
NOTE: This Discharge Summary is being done prior to the
patient's anticipated discharge and an Addendum will be
dictated should there be any changes between now and
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Name8 (MD) 27609**]
MEDQUIST36
D: [**2183-1-24**] 11:40
T: [**2183-1-28**] 08:30
JOB#: [**Job Number **]
Admission Date: [**2182-12-11**] Discharge Date: [**2183-2-12**]
Service:
ADDENDUM
HOSPITAL COURSE: The patient was transferred to the
.................. Intensive Care Unit on [**2-1**] where
he awaited rehabilitation placement. He was transferred to
the regular medical floor on [**2-6**].
In terms of his other issues:
1. Pulmonary: The patient remained with tracheostomy in
place. Ventilation support was gradually weaned off, and the
patient continues to tolerate 40% trach mask with humidified
air with saturations between 95 and 100%.
In terms of his Enterobacter pneumonia, the patient completed
a 14-day course of Ceftriaxone which ended on [**1-26**].
He continued to do well until toward the end of [**Month (only) 956**] when
he developed low-grade fevers and copious sputum production
from his tracheostomy, in addition to a white blood cell
count elevated to about 23. New sputum cultures were
obtained on [**2-6**] which demonstrated greater then 10
PMNs, greater than 10 epithelial cells, and [**12-11**]+ Enterobacter
cloacae growth which was sensitive to Bactrim and Imipenem
but resistant to Ceftazidime. The patient was started on
Bactrim on [**2-6**] and will continue this for a 14-day
course, 200 mg IV q.24 hours after hemodialysis.
The patient was also noted to have bilateral pleural
effusions on chest x-ray of [**2-6**] which were unchanged
from prior chest x-ray and no new pneumonia or consolidations
were noted.
2. Infectious disease: The patient developed a sacral
decubitus ulcer about 5 x 5 cm in diameter which was
subsequently debrided by Surgery. Wound cultures
demonstrated Enterobacter which similar to his sputum
cultures was sensitive to Bactrim and Imipenem but resistant
to Ceftazidime. For concern of osteomyelitis, the patient
underwent bone scan on [**2183-2-11**]. Whole body images of
the skeleton demonstrated areas of increased uptake in the
distal femurs and in three contiguous left posterior ribs;
however, no foci of abnormal uptake were seen in the lower
lumbar spine, sacrum, or coccyx. Thus there was by bone scan
no evidence of osteomyelitis, and the foci of increased
uptake in the left posterior ribs and distal femurs were felt
to be likely posttraumatic in etiology.
The patient will continue wound care with triple creme,
Desitin, and hydrogel to the coccyx ulcer b.i.d. after
cleansing with saline and wound dressing changes. As per
Surgery, the ulcer should be debrided by dressing changes
q.d. to b.i.d.
3. Fluids, electrolytes, and nutrition: The patient is
currently receiving tube feeds via G-J tube which was placed
by Interventional Radiology. He is currently receiving FS
Nepro at 30 cc/hr with 40 g ProMod. This is continuous. It
was attempted to cycle his tube feeds, but difficulty with
G-J clogging was encountered, and the PEG tube had to be
replaced over a wire on [**2-10**]. Swallow studies were
attempted on [**2-6**], but the patient was uncooperative
and will be reattempted at a further point. The patient is
also receiving supplementation with Vitamin E 400 IU per G-J
tube, Vitamin C 500 mg b.i.d. per G-J tube. Remegel has been
attempted, but given that it clogs the G-J tube, we will
attempt TUMS 500 mg t.i.d. at this time.
4. Renal: The patient is with end-stage renal disease and
will continue hemodialysis on Monday, Wednesday, and Friday
schedule.
5. Endocrine: Insulin-dependent diabetes mellitus: The
patient has continued NPH and regular Insulin sliding scale
with no further issues at this point.
Adrenal insufficiency: The patient had been placed on
Prednisone in the [**Hospital Unit Name 153**] for hypotension and status post result
of cortisol stimulation test. The Prednisone was tapered
down and discontinued on [**2-9**]. This was monitored, and
the patient held his blood pressure with no further issues.
6. Ophthalmology: The patient is with a history of
glaucoma, and Timolol, Pilocarpine, Xalatan, Alphagan drops
were continued q.d. with no further issues.
7. Cardiovascular: The patient is status post a non-Q-wave
myocardial infarction with troponin leak of 10 in the
Intensive Care Unit. We continued Lopressor and Aspirin
during the course of this admission with no further issues.
8. CODE STATUS: THE PATIENT IS FULL CODE. The status will
need to be readdressed in the future with the family.
DISPOSITION: The patient will be discharged to
rehabilitation in an acute hospital setting.
DISCHARGE MEDICATIONS: Heparin 5000 mg subcue b.i.d., Epogen
11,000 U three times a week at hemodialysis, Lopressor 25 mg
b.i.d. via G-tube, Zinc 220 mg q.d. via G-tube, Vitamin C 500
mg b.i.d., Remegel discontinued and replaced with TUMS 500 mg
t.i.d. per G-tube, Vitamin E 400 IU q.d., Timolol drops
b.i.d., Pilocarpine GTT O.U. b.i.d., Xalatan 1 GTT O.U.
q.h.s., Alphagan 1 GTT O.U. b.i.d., Natural Tears 1 GTT O.U.
t.i.d., Trusopt 1 GTT O.U. b.i.d., NPH 20 U q.a.m., 15 U
q.p.m., regular Insulin sliding scale, Ranitidine 150 mg per
G-tube q.d., Aspirin 325 mg per G-tube q.d., triple creme 1
jar to affected areas p.r.n., Desitin 1 jar to affected areas
p.r.n., Hydrogel to coccyx ulcer b.i.d. after cleaning with
saline, Bactrim 200 mg IV q.24 hours given after hemodialysis
on hemodialysis days for 8 more days, FS Nepro with 40 g
ProMod at 30 cc/hr via NG tube, Tylenol 500 p.r. per G-tube
q.6 hours standing dose, Lopressor 25 mg b.i.d. per G-tube.
DISCHARGE STATUS: Discharged to acute rehabilitation.
DISCHARGE DIAGNOSIS:
1. Peripheral vascular disease.
2. Status post bilateral above-knee amputation.
3. Adrenal insufficiency status post Prednisone taper.
4. Respiratory failure secondary to aspiration pneumonia
status post failed extubation with percutaneous tracheostomy.
5. End-stage renal disease on hemodialysis.
6. Insulin-dependent diabetes mellitus.
7. Sacral decubitus ulcer.
8. Enterobacter tracheal bronchitis on Bactrim intravenous
antibiotic therapy.
9. Status post non-Q-wave myocardial infarction in mid
[**Month (only) 956**] with troponin leak to 10.
DR.[**First Name (STitle) 2416**],[**First Name3 (LF) 2415**] 12-929
Dictated By:[**Last Name (NamePattern1) 19212**]
MEDQUIST36
D: [**2183-2-12**] 07:59
T: [**2183-2-12**] 08:01
JOB#: [**Job Number **]
RT [**2183-2-12**]
|
[
"707.0",
"410.71",
"518.81",
"403.91",
"427.31",
"707.15",
"440.24",
"507.0",
"730.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"86.22",
"96.72",
"31.1",
"44.32",
"84.15",
"84.17",
"84.12"
] |
icd9pcs
|
[
[
[]
]
] |
17097, 17892
|
16582, 17073
|
22288, 23280
|
23301, 24115
|
7817, 8874
|
17910, 22264
|
7467, 7790
|
2510, 6557
|
1516, 2481
|
15935, 16561
|
6575, 6607
|
6636, 7161
|
7183, 7444
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,147
| 106,231
|
10247
|
Discharge summary
|
report
|
Admission Date: [**2138-7-18**] Discharge Date: [**2138-7-23**]
Date of Birth: [**2078-1-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Peanut
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2138-7-18**] Coronary bypass grafting x2 with the left internal
mammary artery to left anterior descending artery and a free
left radial artery graft to the first obtuse marginal artery
History of Present Illness:
60 year old male with known coronary artery disease, history of
stents to LCx/RCA in [**2126**], HTN, hyperlipidemia reports while
mowing the lawn a few weeks ago he developed anterior chest
tightness that radiated to his jaw and was relieved with rest.
He had a recurrance of this with similar activity several days
thereafter. He presents to OSH for further cardiac workup.
Cardiac cath reveals severe multivessel coronary artery disease.
He was transferred to [**Hospital1 18**] for evaluation of revascularization.
Past Medical History:
Coronary artery disease s/p stent LCX/RCA in [**2126**]
Hypertension
Hyperlipidemia
Asthma
Obstructive sleep apnea
Anxiety/depression
Restless leg syndrome w/ tremors
Benign prostatic hypertrophy
Chronic kidney disease
Past Surgical History:
s/p Laser prostatectomy [**2136**]/circumcision
Social History:
Race:white
Last Dental Exam:4months ago
Lives with:wife
Contact: [**Name (NI) **] Wife Phone #home:
[**Telephone/Fax (1) 34131**], Cell [**Telephone/Fax (1) 34132**]
Occupation:retired [**Company 22916**] packing engineer, works part time
for FEMA
Cigarettes: Smoked no [x]
ETOH:rare
Illicit drug use: None
Family History:
Father MI in 50s-expired in his 60s
Physical Exam:
Pulse:50 SB Resp: 14 O2 sat: RA 100%
B/P Right: 123/81 Left: 117/75
Height:5ft 7" Weight:97kg
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None
Pertinent Results:
Echo [**2138-7-18**]: PRE BYPASS: 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. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results in the operating room at the time of
the procedure.
POST BYPASS: The patient is atrially paced. There is normal
biventricular systolic function. The mitral regurgitation is now
trace. The thoracic aorta is intact after decannulation.
Carotid U/S [**2138-7-18**]: There is less than 40% stenosis in the
internal carotid arteries bilaterally.
[**2138-7-23**] 04:57AM BLOOD WBC-5.2 RBC-2.81* Hgb-9.1* Hct-24.4*
MCV-87 MCH-32.4* MCHC-37.2* RDW-13.0 Plt Ct-150
[**2138-7-20**] 04:31AM BLOOD PT-12.4 INR(PT)-1.0
[**2138-7-23**] 04:57AM BLOOD Glucose-113* UreaN-38* Creat-1.8* Na-139
K-3.9 Cl-99 HCO3-30 AnGap-14
[**Known lastname **],[**Known firstname **] [**Medical Record Number 34133**] M 60 [**2078-1-16**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2138-7-22**]
11:51 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2138-7-22**] 11:51 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 34134**]
Reason: eval left ptx
Final Report
TECHNIQUE: Semi-erect portable radiograph of chest.
Comparison was made with prior radiographs through [**2138-7-18**].
INDICATION: 60-year-old man with status post evaluation of the
left
pneumothorax.
FINDINGS: Left apical pneumothorax is stable since [**2138-7-21**]. Basal lung
atelectasis is unchanged. There is no consolidation. Effusion if
any is
minimal bilaterally. Sternotomy sutures are intact. Heart size
is top normal.
The tip of right internal jugular is terminating into the SVC.
IMPRESSION: Stable minimal left apical pneumothorax since [**7-21**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 16988**] [**Name (STitle) 16989**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: WED [**2138-7-23**] 8:22 AM
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from outside hospital after cardiac
cath revealed severe left main coronary artery disease. He was
initially admitted to the CVICU and underwent pre-operative
work-up. He was then brought to the operating room later on this
day where he underwent a coronary artery bypass graft x 2.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one he was started on beta-blockers and diuretics and
diuresed towards his pre-op weight. Later this day he was
transferred to the step-down floor for further care. His Foley
was removed on post-op day one but he had failure to void and
was reinserted on post-op day two. Chest tubes and epicardial
pacing wires were removed per protocol. On POD# 4 he had a
successful voiding trial and he was discharged to home on POD#5
in stable condition. His discharge creatinine is 1.9 which is
elevated from preop creatinine of 1.3, but is has stabilized.
Medications on Admission:
Atenolol 50mg daily
Simvastatin 40mg daily
Aspirin 81mg daily
Celexa 40mg daily
Mirapex 0.125mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
8. isosorbide mononitrate 10 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily) for 3 months.
Disp:*90 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Mirapex ER 1.5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 2
Past medical history:
s/p stent LCX/RCA in [**2126**]
Hypertension
Hyperlipidemia
Asthma
Obstructive sleep apnea
Anxiety/depression
Restless leg syndrome w/ tremors
Benign prostatic hypertrophy
Chronic kidney disease
Past Surgical History:
s/p Laser prostatectomy [**2136**]/circumcision
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: trace bilateral LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check [**Telephone/Fax (1) 170**] in [**Hospital Ward Name **] 2A on [**7-29**] at 11:15 AM
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**8-14**] at 1:15PM in the [**Hospital **]
medical office building [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2138-8-15**]@ 3:30 PM.
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-25**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2138-7-23**]
|
[
"788.20",
"414.01",
"585.9",
"278.00",
"V45.82",
"V15.01",
"403.90",
"333.94",
"272.4",
"300.4",
"V85.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8096, 8171
|
5202, 6324
|
284, 474
|
8564, 8795
|
2420, 5179
|
9718, 10486
|
1695, 1732
|
6476, 8073
|
8192, 8253
|
6350, 6453
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8819, 9695
|
8494, 8543
|
1747, 2401
|
234, 246
|
502, 1022
|
8275, 8471
|
1351, 1679
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,852
| 184,087
|
50263
|
Discharge summary
|
report
|
Admission Date: [**2121-3-30**] Discharge Date: [**2121-4-1**]
Date of Birth: [**2065-3-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6780**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
56 yoF w/ h/o HTN, Type II DM, hyperlipidemia p/w cough,
abdominal pain, and fevers X 2 days. Pt reports h/o chronic
cough for the last several months, generally non-productive.
However, over the last 3 days cough has become more severe and
is now productive of clear sputum (no hemoptysis). (+) dull
central chest pain, only w/ coughing, no radiation. It is
associated with fevers (to 102 at home), chills, rhinorrhea, and
right ear pain. No sore throat, headache, or neck stiffness. She
also reports intermittent umbilical and epigastric pain X 1
month; she has been told by her PCP that it is due to "reflux."
There has been no recent change in this abdominal pain, which is
burning in character, however she does note nausea/vomiting for
the last 2 days (bilious, no hemetemesis or coffee ground
emesis). (+) decreased PO intake. (+) myalgias. No dysuria,
although reports incontinence w/ coughing. No recent travel or
sick contacts. In [**Name2 (NI) **] T 103.5, pc 102, bp 241/131, resp 24, 90%
RA. Received Ceftriaxone 1 g IV X 1 for suspected pneumonia.
Past Medical History:
PMHx
1) Hypertension
2) Hyperlipidemia
3) Type II DM
4) Morbid obesity
5) s/p hysterectomy [**2085**]
6) mild transaminitis (?NASH)
7) Atypical chest pain
- [**2121-2-14**] PMIBI: No anginal symptoms or ischemic EKG changes.
Normal myocardial perfusion in a setting of soft tissue
attenuation.
- [**1-1**] TTE: Moderate symmetric LVH, LVEF 50%, trivial MR, mild
PA sys HTN, trivial/physiologic pericardial effusion.
Social History:
Lives with daughter in [**Location (un) 686**]
PreSchool Teacher
Denies ETOH, tobacco use
Family History:
Mother and father deceased [**1-29**] brain tumors.
Physical Exam:
PE on Discharge:
T 98.2 HR 66 BP116/78 RR 18 PulseOx 96% RA
Gen: Well appearing, A+Ox3, NAD
HEENT: oral MMM, no LAD/thyromegally
CV: no JVD/carotid bruits, distant HS, RRR no m/r/g
Pulm: CTABL
Ab: S/NT/ND/NM/NHSM +BS
Ext: No LLE, 2+DPPBL
Pertinent Results:
[**2121-3-30**] 07:50PM TSH-2.2
[**2121-3-30**] 07:50PM WBC-7.1 RBC-5.21 HGB-14.5 HCT-42.8 MCV-82
MCH-27.9 MCHC-33.9 RDW-15.2
[**2121-3-30**] 07:50PM cTropnT-0.05*
[**2121-3-30**] 07:50PM CK-MB-2
[**2121-3-30**] 07:50PM ALT(SGPT)-62* AST(SGOT)-64* LD(LDH)-388*
CK(CPK)-163* ALK PHOS-141* AMYLASE-53 TOT BILI-1.2
[**2121-3-30**] 07:50PM LIPASE-32
[**2121-3-30**] 07:50PM GLUCOSE-185* UREA N-11 CREAT-1.1 SODIUM-140
POTASSIUM-2.7* CHLORIDE-95* TOTAL CO2-32* ANION GAP-16
Brief Hospital Course:
Patient's symptoms improved significantly in her brief hospital
course:
1)Fever: most likely bronchitis/mild PNA given constellation of
symptoms. Resolved while inpt. Levaquin x 10 days, finished as
outpt.
2)ARF: Pt's Cr went from 0.9 to 1.2, responded well to fluid
boluses, c/w prerenal etiology. UO adequate at time of
discharge. Discussed with PCP who will redraw labs in a few
days.
3)Hypokalemia: Pt's K was 2.6 at admission. Potasium and
magnesium repleted in house and she was discharged on 30mEq
KCL/day per Dr [**Last Name (STitle) 10743**].
4)CHF: Pt with decreased EF (35-40%) per inpt TTE. She will FU
with Cardiology as outpt. Cardiology called and will contact
patient.
5)Pericardial effusion: pt with small effusion on TTE, etiology
is unknown at this time and will be followed as outpt.
6)NIDDM: serum glucose well controlled with SSI, Metformin held
x 48hrs in light of contrast study.
7)Abdominal Pain: resolved day prior to discharge, no
significant intrabdominal pathology noted on CT scan.
Discharge Medications:
1. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-29**]
Puffs Inhalation Q6H (every 6 hours) as needed.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO BID (2 times a day).
9. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Viral illness
Secondary diagnosis:
Cardiomyopathy
CHF with LVEF of 35 to 40%
Discharge Condition:
Good. Pt was able to ambulate with stable oxygen saturation in
the 90 precent range.
Discharge Instructions:
1)Report to the [**Hospital 12091**] Health Center on Monday to obtain
further lab work. A lab slip will be waiting for you at the
front desk.
2)Call [**Hospital 12091**] Health Center at [**Telephone/Fax (1) 93496**] tomorrow to
set up an appointment with Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10743**]. You should be seen in
the next 3-5 days. They are expecting your call.
3. Return to Emergency Department for recurrence of abdominal
pain, fever >101.5, chest pain, difficulty breathing or any new
concerning symptoms.
4) Stop taking your lasix per Dr [**Last Name (STitle) 10743**] until further follow
up.
5) Take all other medicines as prescribed.
Followup Instructions:
1)Call [**Hospital 12091**] Health Center at [**Telephone/Fax (1) 93496**] tomorrow to
set up an appointment with Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10743**]. You should be seen in
the next 3-5 days. They are expecting your call.
2) Cardiology will be calling you with an appointment time. If
you do not hear from them in the next 2 days please call
[**Telephone/Fax (1) 62**] to schedule an appointment.
|
[
"272.4",
"428.0",
"250.00",
"276.8",
"425.4",
"584.9",
"487.0",
"278.01",
"423.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5116, 5122
|
2836, 3863
|
320, 344
|
5262, 5348
|
2329, 2813
|
6082, 6520
|
1998, 2051
|
3886, 5093
|
5143, 5143
|
5372, 6059
|
2066, 2069
|
2083, 2310
|
275, 282
|
372, 1436
|
5198, 5241
|
5162, 5177
|
1458, 1875
|
1891, 1982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,125
| 120,367
|
51400
|
Discharge summary
|
report
|
Admission Date: [**2115-3-7**] Discharge Date: [**2115-4-17**]
Date of Birth: [**2053-12-12**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Biaxin / Azithromycin / Heparin Agents
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 61 year old female with history of triple valve
replacement, on Coumadin, congestive heart failure, AICD
placement and chronic kidney disease, who was transferred from
[**Hospital1 **] after being incidentally discovered to have a subdural
hematoma on CT scan. Patient reports suffering a fall in her
kitchen approximately one month ago. She denies any prodrome
with the fall and attributes the fall to tripping over her
shoelaces, which are often untied. She fell on her bottom and
then fell backwards, hitting her head on the kitchen floor. She
denies any loss of consciousness, though she recalls feeling
dazed for several minutes. She was then able to get up from the
floor without assistance and later saw her PCP. [**Name10 (NameIs) **] INR was
noted to be 2 at that time and she had no evidence of bruising
or focal neurological deficits. She denies having a CT scan
performed at that time. Since the fall, she denies any
headaches, dysarthria, arm or leg weakness until the day of
admission when she was scheduled for a cardiology appointment.
She reports having difficult grasping papers in her hand and was
also complaining of weakness in her left leg, all of which were
new. She additionally reports a frontal headache over the past
few days. Her cardiologist was concerned and referred her to the
[**Hospital1 **] ER where a head CT revealed a SDH with midline shift
which reportedly measured at 12-13mm at the maximal area. She
was additionally supratherapeutic on Coumadin with an INR of
6.8. She was given 2 units of FFP and sent to [**Hospital1 18**] for urgent
neurosurgical evaluation.
In the [**Hospital1 18**] ED, neurosurgery was consulted and a repeat CT scan
was ordered, which showed a subdural hematoma that was slightly
larger, when compared to the previous CT head at [**Hospital1 **]. She
was given 2 more units of FFP for reversal of her INR and 1 [**Location 72557**]. Cardiology was consulted and recommended not correcting
her INR if at all possible, though neurosurgery recommended
aiming for a goal INR of 1.5 to 2. Patient was then admitted to
the MICU for observation.
Upon further interviewing, the patient reports one medication
change recently - Pantoprazole was increased to [**Hospital1 **]
approximately one week ago. She denies any recent antibiotics
and has been taking her Coumadin as directed, 2 mg daily since
Friday. She does report highly variable INRs in the past and is
thus not on a standing dose of Coumadin as it is adjusted per
her INR, which is checked twice a week.
Past Medical History:
- 3 mechanical valve replacements (tricuspid, no history of
rheumatic heart disease. Reportedly, surgeries were due to a
complication from surgical correction of WPW. Last valve
replacement was in '[**85**])
- Diastolic Congestive Heart Failure
- s/p AICD placement
- Chronic Anemia (followed by hematologist, Dr. [**Last Name (STitle) **] at
[**Hospital1 **])
- Peptic Ulcer Disease complicated by gastrointestinal bleeding
- [**Doctor Last Name 13534**] Parkinson White Syndrome
- Parathyroid tumor s/p resection
- Gout
- Chronic Kidney Disease
- Peripheral Vascular Disease with chronic leg ulcers
- Essential Thrombocytopenia
Social History:
Divorced. Son died 4 years ago from cardiomyopathy. Has one
daughter. Lives alone and is independent in ADLS. Smokes 2
cigarettes/day, reports rare alcohol use and denies illicit drug
use. Previously worked as an aide in nursing homes and
hospitals.
Family History:
N/C
Physical Exam:
Vitals: T - 96.2 (ax), BP - 112/49, HR - 60, RR - 18, O2 - 100%
2L
General: Awake, alert, well-related, NAD, A&O x 3
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: Supple, no LAD
Chest/CV: S1, S2 nl, valve clicks appreciated, but no m/r/g
Lungs: CTAB
Abd: Soft, distended, but nontender, no organomegaly
Rectal: Melena, guaiac positive
Ext: No c/c; chronic venous stasis changes with small,
well-circumscribed, non-healing ulcer on right shin
Neuro: CN II - XII intact less mild asymmetry of facial muscle
on right, sensation intact, strength 4/5 in UEs and LEs, though
left leg is weaker than right with upgoing toe on left
(chronic); gait not assessed
Skin: No petechia, no lesions
Pertinent Results:
Chemistries:
[**2115-3-7**] 06:50PM GLUCOSE-80 UREA N-93* CREAT-2.6* SODIUM-138
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-18* ANION GAP-20
[**2115-3-7**] 06:50PM ALT(SGPT)-6 AST(SGOT)-17 ALK PHOS-169* TOT
BILI-0.8
[**2115-3-7**] 06:50PM LIPASE-28
[**2115-3-7**] 06:50PM ALBUMIN-4.0
Hematology:
[**2115-3-7**] 06:50PM WBC-5.7 RBC-2.73* HGB-8.4* HCT-24.7* MCV-90
MCH-30.6 MCHC-33.8 RDW-18.6*
[**2115-3-7**] 06:50PM NEUTS-74.1* BANDS-0 LYMPHS-16.8* MONOS-6.4
EOS-2.4 BASOS-0.4
[**2115-3-7**] 06:50PM HYPOCHROM-NORMAL ANISOCYT-2+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2115-3-7**] 06:50PM PLT SMR-LOW PLT COUNT-97*
[**2115-3-7**] 06:50PM PT-35.3* PTT-47.4* INR(PT)-3.7*
EKG: Regular atrial pacing with native ventricular conduction.
Non-specific intraventricular conduction delay. Indeterminate
axis. Non-specific ST-T wave changes. No previous tracing
available for comparison.
Imaging:
HEAD CT WITHOUT CONTRAST [**2115-3-7**]: There are bilateral acute on
chronic subdural hematomas, measuring up to 10 mm, overlying
cerebral convexities and extending along the tentorium and falx.
There is 4 mm leftward shift of septum pellucidum. There is no
edema or hydrocephalus. Basal cisterns are patent. Surrounding
soft tissues and osseous structures are unremarkable. Imaged
paranasal sinuses and mastoid air cells are well aerated.
Comparison is made with outside CT performed earlier today.
Acute subdural collection overlying left cerebral convexity is
slightly larger compared to the prior study. The extent of
midline shift is similar.
CT HEAD W/O CONTRAST [**2115-3-8**] 7:48 AM: Bilateral acute on
chronic subdural hematomas overlying both cerebral convexities
and extending along the tentorium and the falx are unchanged.
Shift of normally midline structures towards the left is also
unchanged, measuring up to 6 mm. The basal cisterns are
preserved. There is no hydrocephalus and the [**Doctor Last Name 352**]-white matter
differentiation is preserved. A hypodensity in the left frontal
subcortical white matter likely represents a lacune. Vascular
calcifications are again noted in the vertebral and cavernous
carotid arteries. There is slight decreased pneumatization of
the right frontal sinus and the right mastoid air cells; the
remaining visualized paranasal sinuses and mastoid air cells are
well aerated. The osseous and soft tissue structures including
the orbits are unremarkable.
CHEST (PORTABLE AP) [**2115-3-8**] 11:06 AM: No previous images. The
cardiac silhouette is enlarged in a patient with extensive
sternal sutures and pacemaker device in place. Some evidence of
elevated pulmonary venous pressure. Opacification at the left
base silhouetting the hemidiaphragm could reflect a combination
of atelectasis and pleural effusion.
ECHOCARDIOGRAM [**2115-3-8**]: The left atrium is dilated. The right
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 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. A
bileaflet aortic valve prosthesis is present. The transaortic
gradient is higher than expected for this type of prosthesis.
Trace aortic regurgitation is seen. A bileaflet mitral valve
prosthesis is present. The mitral prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. A mechanical tricuspid valve prosthesis is present.
The tricuspid prosthesis appears well seated, with normal
leaflet motion and transvalvular gradients. The pulmonic valve
leaflets are thickened. There is no pericardial effusion.
Brief Hospital Course:
Assessment: 61 year old woman with acute on chronic subdural
hematomas with midline shift, in the setting of a
supratherapeutic INR.
.
# Subdural Hematoma: The patient presented with left sided
weakness. At the outside hospital she was found to have
evidence of a subdural hematoma and was transferred to this
hospital for neurosurgical evaluation. She was originally
admitted to the medical intensive care unit. Her initial head
CT showed bilateral sudural hematomas with 4 mm leftward shift.
She intially received 5 units of FFP and 1 unit of packed red
blood cells in the intensive care unit. Neurosurgical
intervention was considered elective at that time and was
deferred. She was started on phenytoin for seizure prophylaxis.
She was doing well and was transferred to the floor. Given her
three mechanical heart valves her INR was monitored very closely
and was allowed to trend down. She received 2.5 mg of PO
vitamin K once. Once her INR was less than 2.5 she was started
on intravenous heparin (prior to concern of HIT known) without a
bolus and her coumadin was restarted. Approximately 48 hours
after starting IV heparin she was noted to have mental status
changes on exam. Emergent repeat head CT revealed worsening
bilateral hematomas with worsening midline shift. She was
transferred back to the intensive care unit. During her stay in
the MICU, INR was reversed with 10mg vitamin K and FFP. Pt
underwent successful evacuation of her bleed on [**2115-3-21**]. Pt was
extubated the next morning uneventfully. Her neuro exam has
remained intact. She had a mild L.UE pronator drift and very
subtle weakness in upper and lower extremities. She is on keppra
and being followed by the neurosurgical service as an
outpatient. Per neurosurg recs, she remained off anticoagulation
(INR <1.5) for 8 days after OR procedure. Prior to reinitiation
of anticoagulation, OSH records were obtained for unrelated
reasons, some of which listed HIT as past medical history.
Patient did not know of this history. PF4 antibody was obtained
(returned positive) and hematology was consulted. Argatroban
was initiated and coumadin restarted, initially at small doses
subsequently requiring increase to 5-6 mg daily. INR became
therapeutic (i.e. >4 while on argatroban) on [**4-12**] and she had
overlap of 5 days with both anticoagulants. Discharged on
coumadin with close INR monitoring through her PCP. [**Name10 (NameIs) **] INR was
still supratherapeutic on discharge, she was instructed to hold
coumadin on the night of discharge, and resume coumadin at a
lower dose of 3 mg nightly the day after discharge.
# Valvulopathy: The patient is s/p replacement of tricuspid,
mitral and aortic valves (all mechanical). The target INR for
her valvular disease is between 2.5 to 3.5. The management of
her anticoagulation was complicated as described above by her
sudural hematomas. Anticoagulation initially held, then
restarted with events as described above.
.
# Thrombocytopenia/HIT. Chronic thrombocytopenia with
"essential thrombocytopenia" on OSH notes. ?ITP (treated with
steroids in past). Patient also discovered to have splenomegaly
and cirrhosis, seems to be the more likely cause. GI records
from [**Hospital1 **] were obtained for further GIB history; there were
notes regarding history of HIT. Patient denies past problems
with heparin, and has been on lovenox as recently as last
winter. No signifcant events during 48 hours that patient
received heparin on the floor prior to rebleed (prior to this
history being obtained); platelets stable at that time. PF4
antibody was checked and positive and hematology consulted.
Argatroban used for anticoagulation bridge to coumadin.
.
# Afib with RVR: pt is on nadolol at home; went into Afib with
RVR in MICU, requiring dilt gtt for a time. Now on dilt PO,
rates controlled (in paced rhythm).
.
# Cirrhosis. Per one note from OSH cardiologist and GI doc,
patient with documented history of cirrhosis (diagnosed in
[**2113-5-20**]) but PCP and patient not aware of this history. She was
admitted on unusual regimen including cholestyramine and nadolol
as outpatient. Normal transaminases here. RUQ u/s was ordered
after the above history was eventually obtained; showing
evidence of cirrhosis and portal hypertension. She does have
very elevated ferritin (difficult to interpret given history of
multiple transfusions and acute/chronic illness);
hemachromatosis gene testing was obtained and negative. Hep B
and C negative. No significant EtOH history. We scheduled her
for outpatient followup with Liver Center here for further
outpatient workup. She did have paracentesis during a time in
which patient having unexplained fevers; no evidence of SBP.
.
# Anemia/gastrointestinal Bleeding: The patient has a history
of anemia, gastritis, and peptic ulcer disease; requires
outpatient transfusions (one ever few months). On presentation
she had guaiac positive stools in the setting of a
suprathepeutic INR. Her baseline hematocrit is in the high 20s
and underwent a colonoscopy, endoscopy, and capsule endoscopy
all within the last 4 years for bleeding workup.
Gastroenterology was consulted her but declined workup in the
inpatient setting given guaiac negative stools at the current
time. She required 5 units PRBCs during her course, first at
admission, 2 during neurosurgery, and 2 spaced out during the
rest of her course. She has multiple RBC antigen antibodies as
described by OSH and is difficult crossmatch. PPI continued;
epoetin also started (gets Procrit through her hematologist as
an outpatient).
.
# Stage 4 Chronic kidney disease: The patient's baseline
creatinine 2.0 to 2.5; remained within that range here. Her
medications were renally dosed.
.
# Chronic Diastolic Heart Failure: Ejection fraction preserved
on echocardiogram on [**2115-3-8**]. Patient reports taking variable
diuretic doses. During this admission she was stabilized on
lasix 100 [**Hospital1 **]. At no time did she appear significantly volume
overloaded. She will follow up with her outpatient
cardiologist.
.
# Chronic Leg Ulcers: The patient had a right leg ulcer that was
not healing well. She was seen by our wound care team who
assessed in cleaning and protecting her wound. Significant
improvement seen during this hospitalization.
.
# Kidney lesion. Septated left renal lesion seen on abdominal
ultrasound. She needs f/u MRI as an outpatient to r/o
malignancy.
Medications on Admission:
Allopurinol 100 mg [**Hospital1 **]
Protonix 40 mg [**Hospital1 **]
Nadolol 20 mg [**Hospital1 **]
Clonazepam 1 mg QHS
Furosemide - varies (80 mg to 240 mg with or without Zaroxolyn)
Potassium
Cholestyramine
Prednisone - varies
Zaroxolyn - varies
Tylenol PM PRN
Nasonex PRN
Coumadin - varies
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
Nasal once a day as needed for seasonal allergies.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
8. Outpatient Lab Work
Please have INR checked on Friday, [**4-19**] and have results faxed
to your PCP's office (Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3658**]).
9. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
please do not take a dose tonight (Wed). Start taking on
Thursday night.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Primary:
Subdural Hematoma
.
Gastrointestinal Bleeding
Acute Blood Loss Anemia
Stage 4 Chronic Kidney Disease
Chronic Diastolic Congestive Heart Disease
Cirrhosis
Portal hypertension
Fever
Discharge Condition:
Stable. Ambulating without assistance.
Discharge Instructions:
You were seen and evaluated for your left sided weakness. You
were found to have a subdural hematoma. You were given blood
products to decrease your INR and were evaluated by our
neurosurgeons. You had surgery to remove the bleeding around
your brain and you will followup with the neurosurgeons in the
future.
.
Please take all your medications as prescribed. There have been
several medication changes since you were admitted. Please pay
special attention to the following:
* Please take KEPPRA 500 mg twice daily for preventing seizures.
* Please hold your coumadin dose tonight. Then you may start
taking COUMADIN 3 mg daily on Thursday night (tomorrow). Your
primary care physician will continue to monitor your levels and
make dosing adjustments if needed. You can certainly monitor
your own INRs with your machine. You will have your INR formally
checked by VNA on Friday, who will fax the result to your PCP.
* We have decreased ALLOPURINOL to 100 mg every other day.
* Please take LASIX 100 mg twice daily.
* We have started DILTIAZEM 120 mg daily for heart rate control.
* You should talk with your hematologist about restarting
Procrit injections.
Please keep all your follow up appointment as scheduled.
.
Please seek immediate medical attention if you experience any
fevers > 101.5 degrees, chest pain, difficulty breathing,
lightheadedness or dizziness, numbness, slurred speech, weakness
or any other concerning symptoms.
Followup Instructions:
You have an appointment to follow-up with neurosurgery on [**4-26**], Friday at 1:45 pm. Please report to the [**Hospital Ward Name 23**] Clinical
Building, [**Location (un) **], Spine Center. Call [**Telephone/Fax (1) 1669**] if you have
any questions or need to reschedule. You will also need to get
a CT scan of your head at that time.
.
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
in one week of this admission. Her office phone number is
[**Telephone/Fax (1) 3658**].
.
We have scheduled you with the Liver Center to followup on your
liver disease. The details of this appointment are below:
[**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2115-7-29**]
10:30
.
You will need to have an MRI of your abdomen as an outpatient to
followup on a cyst seen in your kidney. Please discuss this
with your primary care physician to help schedule this.
.
Your INR will need to be monitored closely over the next week.
You may do this either at home or at the lab. Please call your
PCP's office immediately following your discharge to coordinate
this.
Completed by:[**2115-4-17**]
|
[
"285.1",
"287.31",
"305.1",
"287.4",
"427.31",
"707.12",
"276.2",
"V58.61",
"432.1",
"578.1",
"428.32",
"348.4",
"571.5",
"V45.02",
"286.7",
"585.4",
"599.0",
"564.00",
"572.3",
"E879.6",
"786.3",
"E934.2",
"996.64",
"V43.3",
"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
16279, 16341
|
8371, 14824
|
340, 346
|
16574, 16616
|
4595, 8348
|
18108, 19302
|
3857, 3862
|
15167, 16256
|
16362, 16553
|
14850, 15144
|
16640, 18085
|
3877, 4576
|
283, 302
|
374, 2918
|
2940, 3574
|
3590, 3841
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,094
| 164,419
|
34649
|
Discharge summary
|
report
|
Admission Date: [**2147-10-8**] Discharge Date: [**2147-10-27**]
Date of Birth: [**2096-2-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
primary sclerosing cholangitis and cirrhosis here for liver
transplant
Major Surgical or Invasive Procedure:
[**2147-10-8**]: Deceased donor liver transplant with hepatic arterial
conduit and Roux-en-Y hepaticojejunostomy reconstruction.
[**2147-10-12**]: Gravity Cholangiogram
[**2147-10-17**]: Unsuccessful attempt PTBD placement
History of Present Illness:
The patient is a 51-year-old man with primary sclerosing
cholangitis which has led to the development of cirrhosis and
end-stage liver disease. He has no evidence of
cholangiocarcinoma. He was noted on preoperative surveillance
imaging to have a partial portal vein thrombosis and has been
maintained on Coumadin with evidence of regression of the clot
on his most recent imaging no anorexia, no constipation, no CP,
no SOB, no dysuria or hematuria, no melena or hematochezia, no
hematemesis, no change in stool or urine color, no myalgias or
arthralgias, no fatigue, no weight change.
Past Medical History:
UC, primary sclerosing cholangitis, portal HTN, esophageal
varices (scoped [**2144**] ?????? G1 esophageal, G1 w/portal HTN)
Past Surgical History: lap umbo HR [**2145**] (Narahari), lap umbo HR
[**2146**] ([**Last Name (un) 79468**])
Social History:
He had a tattoo back in college. No transfusions. No IV drug
use. No recreational drug use. No tobacco. He has had
rare
alcohol use in the last 15 years, social in the past. He lives
with his wife and his teenage son; aged 17 He has a grown
daughter aged 29, who lives nearby.
Family History:
Significant for a father who had liver disease, it is unclear
whether he also had primary sclerosing cholangitis. No other
family history.
Physical Exam:
Vitals-
temp-98.1F
BP-110/69mm Hg
HR-59/min
RR-18/min
SpO2-98% RA
CVS-S1 S2 heard
RS-bilateral normal breath sounds
Abd-soft, non tender, non distended, bowel sounds+
Extr-warm, edema+, pulses palpable
Pertinent Results:
On Admission: [**2147-10-8**]
WBC-5.9 RBC-3.82* Hgb-12.6* Hct-37.5* MCV-98 MCH-33.0* MCHC-33.7
RDW-17.3* Plt Ct-153
PT-37.5* PTT-38.7* INR(PT)-3.9*
Glucose-87 UreaN-27* Creat-1.6* Na-132* K-5.6* Cl-97 HCO3-27
AnGap-14
ALT-61* AST-126* AlkPhos-305* TotBili-3.3*
Albumin-3.3* Calcium-8.8 Phos-3.4 Mg-1.9
At Discharge: [**2147-10-27**]
WBC-9.7 RBC-2.62* Hgb-8.5* Hct-24.6* MCV-94 MCH-32.6* MCHC-34.6
RDW-17.2* Plt Ct-251
PT-14.0* PTT-23.5 INR(PT)-1.2*
Glucose-95 UreaN-19 Creat-1.3* Na-133 K-4.2 Cl-100 HCO3-29
AnGap-8
ALT-180* AST-37 AlkPhos-195* TotBili-0.9
Albumin-2.2* Calcium-7.9* Phos-3.0 Mg-2.0
tacroFK-10.9
*****
[**2147-10-18**] ProtCFn-97 ProtSFn-30* ProtSAg-PND
[**2147-10-24**] Lupus-NEG
[**2147-10-24**] ACA IgG-PND ACA IgM-PND
[**2147-10-26**] AT-PND
Brief Hospital Course:
51 y/o male with PSC and cirrhosis, portal vein thrombus on
coumadin admitted for liver transplant. The patient was taken to
the OR by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. At the time of surgery, the patient
had known replaced right anatomy and no suitable artery was
found in this region. Very small vessels were also noted in the
celiac axis, none deemed suitable for inflow to the new liver. A
supraceliac donor iliac extension graft was performed. The
conduit was based on the common iliac and external iliac artery.
An end-to-side anastomosis was created from the donor common
iliac artery and of the conduit to the supraceliac aorta. The
recipient portal vein had a
slightly thickened wall but a clearly open lumen. Given the
patient's history of PSC, a Roux reconstruction of the bile duct
was planned. An appropriate
loop of jejunum was identified, that would reach easily into
the right upper
quadrant was identified, the mesentery was divided for a short
distance to allow
full mobilization. An end-to-side hepaticojejunostomy was
created, a 5-French feeding tube was introduced through the
abdominal wall and then into the Roux
limb itself below the colon. It was tunneled through the bowel
and brought up to the anastomosis. The tube was placed across
the anastomosis and into the common hepatic duct. Two JP drains
were also placed. He tolerated the surgery without complication,
receiving 1 unit RBCs, 8 units FFP and 8 Liters crystalloid. He
was transferred to the ICU in stable condition.
Induction immunosuppression per pathway was used, solumedrol 500
mg intra-op, cellcept 1 gram [**Hospital1 **] and Prograf started on POD 1.
The patient was extubated on POD 1 following an ultrasound
evaluation per protocol. Appropriate arterial waveforms are seen
in the main hepatic artery, the
anterior right hepatic artery and the left hepatic artery.
Despite diligent
effort, the posterior left hepatic artery could not be
identified. Appropriate flow is also seen in the IVC and the
hepatic veins. Liver enzymes initially elevated to the low
1000's, but these were trending down daily.
Roux study on POD 4 showed that this was a non-diagnostic exam
as the tip of the surgically-placed biliary catheter had
migrated distally to the Roux-en-Y limb.
On POD 5 a HIDA scan was performed, showing findings suggestive
of a possible bile leak with good external drainage. It is also
possible the radiolabeled tracer normally entering the jejunum
is draining externally from the tube within the jejunum. there
was no tracer pooling in the peritoneum. The medial drain has
always appeared dark in color.
LFTs were on a downward trend until POD 7 when labs were noted
as follows: AST went from 91 to 435, ALT from 205 to 665, Alk
phos 117 to 125 and T Bili from 1.7 to 2.5.
Due to the LFT elevations and also the probable bile leak, a CTA
was obtained which showed:
** Complete occlusion of the donor iliac conduit arising from
the supraceliac
aorta, approximately 2 cm distal to its aortic takeoff.
** Hypoattenuation along the portal veins, concerning for
biliary necrosis.
** Hypoenhancement of segment II, III and IVb concerning for
infarction with
air noted in the biliary system of segment IVb.
** Multiple areas of narrowing of the left and right portal,
main portal vein
and left intrahepatic portal veins as described above.
Due to these findings, it was determined that the patient should
be relisted for liver transplant.
He was started empirically on Vanco and Zosyn, with levels
followed by trough levels as he is also noted to have acute on
chronic renal failure. (Admission creatinine was 1.6 with
highest level of 2.7 noted, which eventually came back down to
1.3)
He received 10 days of the Vanco and Zosyn and then was switched
to PO Augmentin. He never was febrile during this
hospitalization.
A Hematology workup and lab evaluation for causes of the
thrombotic picture was undertaken. A HIT was sent which came
back positive, however the SRA was negative and the patient was
not anticoagulated. Multiple lab results remain pending at the
time of his discharge. He was not sent home on warfarin.
The patient was quite fluid overloaded, in part due to the
chronic renal failure picture. He was diuresed with furosemide,
receiving some additional IV doses in addition to an oral
regimen. He was also wearing TEDS with excellent relief of the
bilateral lower extremity edema.
He was tolerating a regular diet, had return of bowel function
and was ambulating extensively in the halls.
The patient has started the use of insulin during this
hospitalization for which he received teaching and supplies and
insulin scripts were given at discharge.
The patient will be discharged with both drains in place.
Staples were d/c'd prior to discharge.
It was determined that the patient could be safely monitored
from home. Extensive teaching was provided regarding signs and
symptoms to watch for with both the patient and his wife. [**Name (NI) **]
will also have VNA coverage and twice weekly labs.
Medications on Admission:
nadolol 40', lasix 40', spirinolactone 100', calcium, mvt,
coumadin 2', ursodiol 300'''
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. prednisone 5 mg Tablet Sig: 3 1/2 Tablets PO once a day:
Follow transplant clinic taper.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 30 days.
Disp:*90 Tablet(s)* Refills:*0*
11. FreeStyle System Kit Kit Sig: One (1) kit Miscellaneous
once a day.
Disp:*1 kit* Refills:*0*
12. FreeStyle Lancets Misc Sig: One (1) lancet Miscellaneous
four times a day.
Disp:*2 boxes* Refills:*12*
13. Freestyle Strips
Sig: Test 4 times daily
Disp: 150 strips
Refills: 12
14. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day.
Disp:*2 Vials* Refills:*12*
15. Insulin Syringe Ultrafine [**12-3**] mL 29 x [**12-3**] Syringe Sig: One
(1) Miscellaneous four times a day.
Disp:*1 box* Refills:*6*
16. Kayexalate Powder Sig: Four (4) tsp PO As directed by
transplant clinic.
17. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
18. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PSC now s/p liver transplant
thrombosis of celiac-HA conduit and infarction of segment IVb
now
relisted for liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please clal the transplant center at [**Telephone/Fax (1) 673**] for increased
confusion, increased fatigue, fever, chills, nausea, vomiting,
increased abdominal pain, yellowing of skin or eyes, inability
to take or keep down food, fluids or medications, or any
concerning symptoms.
Drain and record the JP bulb drain output twice daily and as
needed. Monitor the output for changes in appearance such as
more bloody in appearance, darker green in color or if it
develops a foul odor. Bring a copy of the drain output records
with you to your appointments.
You may shower. Pat incisions dry, do not rub. Steri strips will
come off on their own. Place new drain sponges around the drains
after your shower or daily. Monitor all areas for redness,
drainage or bleeding. Do not allow the drains to hang freely at
any time.
No baths or swimming. No heavy lifting
No driving if taking narcotic pain medication.
Labs every Monday and Thursday. You may have labs drawn at Quest
one time a week and at the [**Hospital Ward Name **] lab on time a week.
Wear your TEDS at least 12 hours daily. Weigh yourself daily and
call office if your weight changes by more than 3 pounds in a
single day or if you note leg swelling or if you are very
thirsty. Drink enough fluids to keep your urine light yellow in
color.
Followup Instructions:
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-11-2**] 2:10
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-11-9**] 1:00
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-11-16**] 1:00
Completed by:[**2147-10-27**]
|
[
"997.4",
"996.82",
"E878.0",
"452",
"573.4",
"572.3",
"571.5",
"V58.61",
"V49.83",
"585.9",
"584.9",
"576.1",
"572.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"87.54",
"00.93",
"87.51"
] |
icd9pcs
|
[
[
[]
]
] |
9840, 9889
|
2980, 8027
|
386, 611
|
10063, 10063
|
2193, 2193
|
11538, 12000
|
1811, 1954
|
8166, 9817
|
9910, 10042
|
8053, 8143
|
10214, 11515
|
1398, 1487
|
1969, 2174
|
2509, 2957
|
275, 348
|
639, 1227
|
2207, 2495
|
10078, 10190
|
1249, 1375
|
1503, 1795
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,173
| 122,478
|
3463
|
Discharge summary
|
report
|
Admission Date: [**2105-7-26**] Discharge Date: [**2105-7-30**]
Date of Birth: [**2060-4-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
alcohol withdrawl
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 634**] is a 45 yo female w/ PMH of EtOH abuse c/b
withdrawal seizures, Hepatitis B, Hepatitis C, h/o CM resolved
on recent echo who presented to [**Hospital1 18**] ED on [**2105-7-26**] w/ EtOH
withdrawl and ARF. Of note, her last admission to [**Hospital1 18**] was
[**Date range (1) 15952**] when she fell and withdrew from EtOH. She
required 2 days of IV valium.
.
On admission, the pt reported that she has not had a drink in
five weeks, but on the day prior to admission she had one pint
of vodka. On the morning of admission, she had two Heinekens at
7:30am. Later that day she had nausea and multiple episodes of
nonbloody, bilious vomiting. She also reports diffuse abdominal
pain x 2-3 days, sharp, intermittent, and worse with PO intake.
She stopped eating over this time due to its worsening her abd
pain.
.
She came to the ED b/c she started seeing white spots and
feeling "anxious and jittery". She reports this is how she felt
prior to having a seizure in the past so she was worried she was
going to have a seizure. She does admit to "sniffing" cocaine 2
days prior to admission and occassionally feeling jittery when
she sniffs cocaine.
.
In the ED, VS on arrival were: T: 100.9; HR: 120; BP: 136/82;
RR: 20; O2: 97 % RA -->89% RA when sleeping. She was given 2mg
of ativan x 2 and 5 mg metoprolol IV.
.
ROS: otherwise negative. No chest pain, shortness of breath,
cough. No current n/v. No diarrhea, melena, hematochezia. No
constipation. No easy bruising/bleeding. No dysuria, hematuria.
No bladder/bowel incontinence. No myalgia/arthralgia/rash.
Past Medical History:
1. Hepatitis B: dxed [**2098**] per pt
2. Hepatitis C: dxed [**2098**] per pt
3. Pancreatitis: h/o pseudocyst drainage
4. EtOH abuse as above, c/b withdrawal seizures.
5. h/o heroin abuse
6. cardiomyopathy: dx in [**2-23**] at NWH. EF 20%. unknown etiology
(likely [**2-19**] EtOH), recent echo [**4-23**] with nl EF.
7.h/o NSVT: at OSH in [**2-23**]
8. h/o depression: dx at NWH in [**2-23**], unsure if bipolar d/o.
9. h/o SDH in [**3-22**] in setting of [**4-17**] generalized tonic clonic
seizure from EtOH withdrawal.
Social History:
The patient is married and lives in [**Location 745**] with husband. [**Name (NI) **] 2
children, ages 21 and 26 who do not live with her. Drinks Vodka
at least 1 pint per day. Smokes 0.5-1 pk cig/day x 10 yrs. Last
cocaine use 2 yrs ago. Last heroin use 2 yrs ago.
Family History:
Father with HTN and alcoholism. No h/o seizure disorder. Her
sister has a history of drug use but is now clean.
Physical Exam:
On admission (per ICU):
Gen: NAD, lying in bed.
HEENT: PERRLA; EOMI; sclera anicteric; conjunctiva not pale; MM
sl dry, no OP lesions.
Neck: No LAD, supple
CV: rrr. nl S1S2. no m/g/r.
Lungs: clear to auscultation and percussion b/l
Abd: +NABS. soft, ND. + tender to palpation - epigastric region.
no rebound/guarding. No organomegaly appreciated. Midline
abdominal scar.
Back: No CVAT.
Ext: No edema. DP 2+.
Neuro: CN II-XII intact. A&O x 3. [**5-22**] UE/LE b/l. No asterixis.
Pertinent Results:
[**2105-7-26**] 02:15PM GLUCOSE-152* UREA N-19 CREAT-3.0*# SODIUM-135
POTASSIUM-6.2* CHLORIDE-85* TOTAL CO2-24 ANION GAP-32*
[**2105-7-26**] 02:15PM ALT(SGPT)-363* AST(SGOT)-3268* ALK PHOS-114
AMYLASE-412* TOT BILI-1.3
[**2105-7-26**] 02:15PM LIPASE-1312*
[**2105-7-26**] 02:15PM ALBUMIN-4.3 CALCIUM-7.7* PHOSPHATE-7.4*#
MAGNESIUM-0.9*
[**2105-7-26**] 04:51PM LD(LDH)-1233* CK(CPK)-869*
[**2105-7-26**] 02:22PM LACTATE-3.7* K+-4.8
[**2105-7-26**] 04:51PM TRIGLYCER-565*
[**2105-7-26**] 02:15PM WBC-6.9# RBC-3.53*# HGB-11.9* HCT-33.8*
MCV-96# MCH-33.8* MCHC-35.3* RDW-18.2*
[**2105-7-26**] 02:15PM PLT SMR-VERY LOW PLT COUNT-75*#
[**2105-7-26**] 04:51PM VIT B12-1694* FOLATE-10.1
[**2105-7-26**] 02:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2105-7-26**] 05:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2105-7-26**] 05:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG
[**2105-7-26**] 05:45PM URINE RBC-[**3-22**]* WBC-[**3-22**] BACTERIA-MANY
YEAST-NONE EPI-[**12-7**] TRANS EPI-[**3-22**] RENAL EPI-0-2
[**2105-7-26**] 09:11PM URINE HOURS-RANDOM CREAT-370 SODIUM-24
[**2105-7-26**] 09:11PM URINE OSMOLAL-437
MICRO:
[**2105-7-26**]: UCX - >[**Numeric Identifier 4856**] ECOLI
.
[**2105-7-26**]: Bld Cx x 1 - NGTD
.
EKG: Sinus at 125. nl axis. nl intervals. no ST changes.
.
Radiology:
RUQ US [**2105-7-27**] -
1. Dilated common bile duct up to 10 mm without evidence for
filling defects or stones.
2. Heterogeneous echogenic liver consistent with fatty
infiltration.
.
CXR AP [**2105-7-26**] - no pneumonia or pulmonary edema.
Brief Hospital Course:
1. EtOH withdrawal
While in the [**Hospital Unit Name 153**], the patient was maintained on a CIWA scale
and required a total of 15 mg IV valium over the first 12 hours.
She was called out to the floor on hospital day #2. On the
floor she was given 10 mg po dilaudid q1-2h for CIWA > 10. This
was weaned to off over the next 3 days. The patient had
occasional anxiety fits on the floor but would often calm down
before receiving benzo. Thus, her CIWA scores were difficult to
follow. Social work was consulted to aid the patient with her
substance abuse. Given her concurrent anxiety, the patient was
referred to [**Location (un) 15953**] Community Care in [**Location (un) 745**] for counseling.
She was advised to abstain from alcohol and counseled on its
numerous harmful effects. Throughout her stay she was
maintained on folate, thiamine, and a multivitamin. Serum
folate and B12 during this admission were within normal limits.
.
2. Etoh pancreatitis:
Patient presented with a lipase of 1312 in the setting of recent
alcohol ingestion. She complained of RUQ and epigastric pain.
A RUQ ultrasound was done and showed a dilated common bile duct
without evidence of stones and a normal pancreas. Her bilirubin
was initially slightly elevated but with a normal alkaline
phosphatase and returned to [**Location 213**] by the time of discharge.
Her lipase, in addition to her LFTs improved with bowel rest and
IVF. She received morphine for her pain. She had diarrhea in
house but no nausea or vomiting. Her pain quickly improved and
she was advanced to a full diet with excellent tolerance. She
was no longer requiring analgesic medications at the time of her
discharge. Lipase on discharge was 48.
.
3. Etoh hepatitis:
Patient presented with an ALT 363 of and an AST of 3268 after
recent ingestion of alcohol. Her LFTs steadily improved over
the course of her stay and her coags are normal. At the time of
discharge, her ALT 92 was and her AST was 163. Given her
history of hepatitis B and C hepatitis serologies were sent.
Hepatitis serologies were checked during her admission, however
she had an undetectable hep B and C viral load in [**4-23**]. Her
serologies were consistent with past hep B and C infection. As
stated above, her elevated LFTs were consistent with Etoh
hepatitis and improved with conservative treatment.
.
4. ARF:
Creatinine was 3.0 on admission and her FeNa was consistent with
prerenal renal failure. Her creatinine returned to [**Location 213**] with
IVFs.
.
5. Fever
Patient had a temperature of 100.9 on presentation in the
setting of withdrawl. CXR showed no evidence of pneumonia.
Both urine samples were contaminated. Patient denied any
complaints of urinary tract infection and remained afebrile off
antibiotics. Given her complaints of diarrhea, c diff and stool
cultures were sent and were negative.
.
6. Thrombocytopenia
Patient presented with a platelet count of 75. Coags were
normal but her hematocrit was down from baseline with an
elevated bili and recent ARF, concerning for hemolytic process.
However, haptoglobin was within normal limits and her platelets
returned to [**Location 213**]. Suspect this was a suppression due to her
alcohol ingestion.
.
7. Anemia - HCT at baseline at the time of discharge. Her retic
index is low. Iron studies from [**4-23**] do not suggest iron
deficiency. B12 and folate were within normal limits and her
TSH was normal in [**Month (only) 116**]. Most likely her anemia is due to bone
marrow suppression from her alcohol but she will follow-up with
her new primary care doctor for continued monitoring.
.
8. HTN - Patient presented tachy and hypertensive in the setting
of acute withdrawl. She had been prescribed a beta blocker for
treatment of hypertension in the past, but given her history of
recent cocaine ingestion, I have switched her to an ACEI. She
will follow-up with her new primary care doctor for continued bp
management. She was instructed to discard her metoprolol and
warned of the dangerous interaction of this medication with
cocaine.
.
9. Elevated CK - Likely this was due to her alcohol + cocaine
ingestion. Patient denied passing out, recent fall, or
seizures. She was only minimally tremulous on admission. Her
CK peaked at 1047 and was down to 228 at the time of discharge.
She was maintained on IVF until her numbers improved. Despite
normal EKG and no complaints of chest pain or shortness of
breath, a troponin x 1 was checked on hospital day #1 and was
normal.
.
10. Contact: [**Name (NI) 15954**] [**Name (NI) **] [**Telephone/Fax (1) 15955**]
.
11. Prophylaxis: pneumoboots (given low plt), PPI (given
epigastric discomfort/NPO)
.
16. Code Status: Full Code
Medications on Admission:
Metoprolol 75 mg [**Hospital1 **]- has not taken in over one week
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
alcohol withdrawl
alcoholic pancreatitis
rhabdomyolysis
alcoholic hepatitis
anxiety, NOS
thrombocytopenia
hypertension
Discharge Condition:
good, calm and without tremor off benzos, tolerating regular
diet
Discharge Instructions:
Please call your new doctor ([**Telephone/Fax (1) 250**]) or go to the
emergency room if you experience temperature > 101, worsening
abdominal pain, vomiting, or other concerning symptoms.
Please follow-up with [**Location (un) 15953**] Community Care in [**Location (un) 745**] to
establish a therapist who can help you with your anxiety.
Please avoid any further alcohol. It is damaging your pancreas
and your liver.
Please go immediately to the emergency room if you have any
thoughts about hurting yourself.
Followup Instructions:
Please follow-up with your new primary care doctor, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3150**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2105-8-6**] 2:30 at
[**Hospital Ward Name 23**] 6.
|
[
"303.91",
"577.0",
"728.88",
"305.60",
"285.9",
"571.1",
"291.81",
"401.9",
"584.9",
"070.54",
"287.5",
"070.32"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10354, 10360
|
5152, 9857
|
332, 339
|
10523, 10591
|
3428, 5129
|
11154, 11381
|
2802, 2915
|
9973, 10331
|
10381, 10502
|
9883, 9950
|
10615, 11131
|
2930, 3409
|
275, 294
|
367, 1955
|
1977, 2502
|
2518, 2786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,066
| 147,919
|
8115
|
Discharge summary
|
report
|
Admission Date: [**2108-10-28**] Discharge Date: [**2108-11-5**]
Date of Birth: [**2066-7-8**] Sex: F
Service: TRANSPLANT SURGERY
CHIEF COMPLAINT: Fever, nausea and vomiting.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 28926**] is a 42 year-old
female approximately seven weeks status post cadaveric renal
transplant with a postoperative course complicated by a
ureteral leak requiring nephrostomy tube placement and V.A.C.
care to wound as well as a line associated SVC syndrome
requiring Coumadinization. The patient subsequently was
discharged to a rehabilitation center, but now returned to
[**Hospital1 69**] on [**2108-10-28**]
with several day history of fevers, nausea, vomiting. Her
fevers were as high as 101.5. She also reported decrease in
her urine output for one week. Her wound care continued
with no notable signs of infection. The patient continued to
have bowel movements without any evidence of diarrhea. She
was without any abdominal pain, chest pain, shortness of
breath or any respiratory symptoms. At presentation in the
Emergency Department her systolic blood pressure was noted to
be in the 90s requiring intravenous boluses.
PAST MEDICAL HISTORY:
1. Diabetes mellitus insulin dependent.
2. End stage renal disease.
3. Hypertension.
4. Hypothyroidism.
5. Left line associated SVC syndrome requiring
thrombolectomy and Coumadinization.
PAST SURGICAL HISTORY:
1. Status post cadaveric renal transplant on [**2108-9-8**].
2. Status post Perm-A-Cath in the right IJ.
3. Status post AV fistula times three.
4. Status post stenting of the right brachiocephalic and
SVC.
5. Status post SVC thrombectomy on [**9-17**] and [**9-18**].
ALLERGIES: Floxins and Vancomycin.
SOCIAL HISTORY: She is divorced on disability. She denies
any ethanol or tobacco use.
MEDICATIONS ON ADMISSION:
1. Bactrim SS one tab po q day.
2. CellCept 1 gram po b.i.d.
3. Neurontin 100 mg po t.i.d.
4. Lansoprazole 30 mg po q day.
5. Valcyte 350 mg po q.o.d.
6. NPH 22 b.i.d.
7. Zinc 220 mg po q.d.
8. Coumadin 4 mg po q day.
9. Dulcolax 10 mg po b.i.d.
10. Prograf 2 mg po b.i.d.
11. Levoxyl 75 micrograms po q day.
12. Celexa 20 mg po q day.
13. Lipitor 10 mg po q day.
14. Percocet one to two tabs po q 4 to 6 hours prn pain.
15. Lopressor 75 mg po b.i.d.
16. Lasix 40 mg po q day.
17. Vitamin C 500 mg b.i.d.
18. Prednisone 0.5 mg po q day.
PHYSICAL EXAMINATION: Temperature 98.9. Blood pressure
131/46. Heart rate 91. Respiratory rate 17. She was 100%
on 4 liters nasal cannula. General, she was well developed,
well nourished lady in no acute distress. Head, eyes, ears,
nose and throat normocephalic, atraumatic. Anicteric.
Oropharynx without any lesions. They were moist. Neck was
supple. Heart regular rate and rhythm. Respirations clear
to auscultation bilaterally. Abdomen soft, nontender,
nondistended. Packed right lower quadrant wound. The wound
was without any purulent drainage on removal of the V.A.C.
Extremities there was noted for some left ankle skin ulcer.
LABORATORIES ON ADMISSION: White blood cell count 3.5,
hematocrit 37.1, platelets 155, sodium 136, potassium 5.0,
chloride 107, bicarb 18, BUN 42, creatinine 3.1, glucose 83.
[**Name (NI) 2591**] PT 20.8, PTT 37, INR 2.9. Her urinalysis was notable
for moderate amounts of leukocyte esterase, negative nitrite,
21 to 50 white blood cell and moderate bacteria. Chest x-ray
was negative. Renal ultrasound was obtained, which was
negative for hydro. There was no fluid collection. There is
normal arterial wave forms and normal resistive indices.
HOSPITAL COURSE: The patient is a 42 year-old female status
post cadaveric renal transplant on [**2108-9-8**] for end
stage renal disease secondary to diabetes mellitus who had a
postoperative course complicated by a ureteral leak requiring
nephrostomy as well as a V.A.C. to the wound. During that
hospital stay had a line associated SVC syndrome requiring
thrombolectomy. She returned from rehab on [**2108-10-28**]
to [**Hospital1 69**] with fevers and
nausea and vomiting as well as decreased urine output. She
was noted to have a positive urinalysis. Urine culture was
sent. She was initially kept in the Intensive Care Unit for
close monitoring for urosepsis. She was bolused and provided
with intravenous hydration and her blood pressure responded
appropriately. Her urine output improved. She was placed
initially on Zosyn for appropriate antimicrobial coverage.
Her urine culture was followed up, which indicated
Enterobacter cloacae, which was actually resistant to Zosyn
and sensitive to Levofloxacin. At that point she was
switched over to a 14 day course of Levofloxacin. The
patient continued with complaints of nausea and voting. Her
Prograf was discontinued and the patient was switched onto
Imuran and by the time of discharge she was on a 150 mg po q
day. Additionally, since admission the patient's Coumadin
dose had been held secondary to elevated INR, but by the time
of discharge the patient was placed on a Coumadin dose of 0.5
mg po q day and to have a regular biweekly laboratory blood
work drawn including close monitoring of her coagulation.
The patient underwent a nephrostogram, which indicated a
small anastomotic leak. It was thought that it would be best
to keep the nephrostomy tube open for another four weeks and
to repeat the study at that time. Renal function, however,
was improving and was noted to make adequate amount of urine
through the nephrostomy tube. By the time of discharge on
hospital day nine the patient was tolerating a regular diet.
Her nausea and vomiting had resolved and she continued to
make excellent urine output. She was on a immunosuppressant
regimen of Prednisone 5 mg po q day, Tacrolimus 1 mg po
b.i.d. as well as Imuran 150 mg po q day.
DISCHARGE STATUS: To rehabilitation center.
DISCHARGE DIAGNOSES:
1. Urosepsis/urinary tract infection.
2. Hydration.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg po q day.
2. Bactrim SS one tab po q day.
3. Celexa 20 mg po q day.
4. Colace 100 mg po b.i.d.
5. Valcyte 450 mg po q day.
6. Synthroid 75 micrograms one tab po q day.
7. Vitamin C 500 mg po b.i.d.
8. Zinc sulfate 220 mg one tab po q day.
9. Tylenol one to two tabs po q 4 to 6 hours prn.
10. Sulfa 500 mg one tab po b.i.d.
11. Prednisone 5 mg one tab po q day.
12. Albuterol one to two puffs inhalation q 6 hours prn.
13. Robitussin 5 to 10 ml po q 6 hours prn.
14. Reglan 10 mg one tab po t.i.d.
15. Levofloxacin 250 mg one tab po q day for eight more days
for a total of 14 days treatment.
16. Famotidine 200 mg one tab po q day.
17. Imuran 150 mg po q day.
18. Tequin one tab po b.i.d.
19. Percocet one to two tabs po q 4 to 6 hours prn.
20. Zofran 2 mg intravenously q 4 to 6 hours prn nausea and
vomiting.
21. Benadryl 150 mg intravenously q 6 hours prn.
22. Coumadin 0.5 mg one tab po q day.
23. Insulin sliding scale.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] on
Monday [**2108-11-12**] at the Transplant Center, telephone
number [**Telephone/Fax (1) 673**] at 2:40 p.m. She is additionally to call
the Transplant Center for follow up appointments with Dr.
[**Last Name (STitle) **] as well as Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She is additionally to
have laboratories biweekly including CBC, chem 10, [**Last Name (NamePattern1) **],
liver function tests, amylase, lipase as well as Tacrolimus
levels in the a.m. before the a.m. dose is given. She is to
continue to have V.A.C. treatment as well as nephrostomy care
at the rehabiltiatino center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366
Dictated By:[**Last Name (STitle) 28927**]
MEDQUIST36
D: [**2108-11-5**] 11:28
T: [**2108-11-5**] 11:32
JOB#: [**Job Number 28928**]
|
[
"250.00",
"996.74",
"996.81",
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"401.9",
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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5898, 5953
|
5976, 6943
|
1853, 2409
|
3628, 5877
|
1427, 1738
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6955, 7905
|
2432, 3072
|
169, 198
|
227, 1189
|
3087, 3610
|
1211, 1404
|
1755, 1827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,233
| 187,883
|
47416
|
Discharge summary
|
report
|
Admission Date: [**2151-5-7**] Discharge Date: [**2151-5-15**]
Date of Birth: [**2083-3-1**] Sex: M
Service: SURGERY
Allergies:
Lithium / Codeine / Penicillins / Toprol Xl
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
68 year old gentleman with DM and Parkinsons, was admitted with
infected L big toe ulcer
Major Surgical or Invasive Procedure:
Angiogram done on [**2151-5-11**]
ANGIOGRAPHIC FINDINGS:
1. Normal-appearing distal abdominal aorta with mild
diffuse disease but no discrete stenosis or aneurysm.
2. Bilateral common iliac arteries had mild diffuse disease
but were patent.
3. Bilateral hypogastric arteries were patent with diffuse
disease.
4. Bilateral external iliac arteries were widely patent.
5. The left common femoral and profunda femoris artery was
patent.
6. The left superficial femoral artery had some mild
diffuse disease but was patent.
7. The above and below-knee popliteal artery was widely
patent.
8. The anterior tibial artery was occluded and did not
reconstitute.
9. The peroneal artery was occluded and did not
reconstitute.
10.The posterior tibial artery was patent into the level of
the mid calf where it occluded; however, there was a
large collateral that went all the way down to the ankle
and reconstituted the posterior tibial artery.
History of Present Illness:
68 year old gentleman with DM and Parkinsons, with ulcers in
both big toes was sent to the ED for infected L big toe. Was
seen by Dr.[**Last Name (STitle) **] on [**2151-4-28**] for bilareal toe ulcers
chronic and non healing. He had forefoot PVRs done which showed
significant ischemia and he was scheduled for an angiogram on
[**2151-5-11**]. Per nursing home report he has been having fevers last
couple of
days, increasing pain L leg and redness on the medial aspect of
L
leg.
Past Medical History:
PMH:
Chronic Atrial Fibrillation
CHF (EF 45% [**2144**])
Diabetes Mellitus II
CAD ?MI (per pt years ago)
PVD
CRI baseline 1.3-1.7
HTN
hyperlipidemia
GERD
depression s/p suicide attempt on [**2148-6-28**]
mild dementia
anxiety
osteoarthritis L knee
s/p appy
s/p R great toe amputation
[**2148-8-26**] s/p R femoral distal posterior tibial bypass graft
[**9-26**] s/p thromboembolectomy of R fem-tib bypass with patch
angioplasty
[**10-19**] s/p excision of necrotic ischemic graft w/ new alloderm,
and right metatarsal debridement and patch angioplasty.
-Anemia
-BPH
-Low B12
Social History:
Social History: lives at nursing home, divorced with 2 children,
former tobacco, no EtOH or other drug use
Family History:
Family History: non-contributory
Physical Exam:
At admission:
Vital Signs: Temp: 97.8 RR: 20 Pulse: 90 BP: 132/64
Neuro/Psych: Oriented x3, Affect Normal, abnormal: Some
dementia. Was able to respond to questions appropriately
Neck: No right carotid bruit, No left carotid bruit.
Skin: No atypical lesions.
Heart: Abnormal: Irregular.
Lungs: Clear.
Gastrointestinal: Non distended, No masses.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. Popiteal: P. DP: D. PT: P.
LLE Femoral: P. Popiteal: P. DP: D. PT: D.
DESCRIPTION OF WOUND: Bilateral great toe ulcerations. L foul
smelling with necrotic tissue at the base. R great toe ulcer
which is dry
Pertinent Results:
At admission
138 102 26
---------------< 108 AGap=14
3.7 26 1.5
9.6>35< 201
N:76.9 L:12.3 M:6.2 E:4.2 Bas:0.4
At discharge:
pH 7.49 pCO2 39 pO2 197 HCO3 31 BaseXS 6 Type:Art
K:3.7 freeCa:1.14 Lactate:1.2 O2Sat: 98
143 102 22
------------< 66 AGap=17
3.8 28 1.0
CK: 75 MB: Notdone Trop-T: 0.15
Ca: 8.5 Mg: 2.3 P: 3.5
ALT: 16 AP: 82 Tbili: 0.5 Alb: 3.2 AST: 21 LDH: 278
25.4 >37.1< 472
Brief Hospital Course:
Admitted and started on Iv antibiotics:
Vanco (which he was already on) Cipro and Flagyl. Changed to
Cipro to Ceftrioxone on [**2151-5-11**]
Cultures Showed:
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| STAPH AUREUS COAG +
| | STAPH AUREUS
COAG +
| | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- <=0.25 S <=0.25 S
ERYTHROMYCIN---------- <=0.25 S <=0.25 S
GENTAMICIN------------ 8 I <=0.5 S <=0.5 S
LEVOFLOXACIN---------- <=0.12 S <=0.12 S
MEROPENEM-------------<=0.25 S
OXACILLIN------------- 0.5 S 0.5 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S <=0.5 S
He was transferred briefly to the ICU for an episode of
desaturation which was believed to be a mucus plug. His
troponins post episode was elevated. Troponin peaked at 0.43
ng/mL . He had a NSTEMI. They advised continued diuresis and
aspirin and simvastatin.
Angiogram was done on [**2151-5-11**]
L side: The anterior tibial artery and the peroneal artery was
occluded and did not reconstitute. The PT was occluded at the
level of the mid calf and reconstituted at the ankle.
Cardiology was reconsulted for preop clearance for was a
popliteal-posterior tibialis bypass. Cardiac cath was done which
showed two vessel disease.
Cardiac Catheterization:
Date: [**2151-5-13**] Place: [**Hospital1 18**]
LM- moderate disease
LAD- TO proximally, collaterals from RCA
LCx- 95% distal
OM1- multiple 70% lesions
RCA- 40%
Cardiac Echocardiogram:
[**2151-5-9**]
EF 30-35%
1+MR, mildly thickened MV leaflets
Cardiac surgery was consulted for coronary bypass prior to LE
bypass.
On [**2151-5-14**] he had multiple issues:
Elevated WBC: 16 Blood and urine cultures were sent
During the course of the day his mental status deteriorated was
becoming more somnolent. Speech and swallow was requested. He
was made NPO.
He went into afib which was being treated with Dilt boluses and
drip.
He acutely desaturated. Lots of secretions. Appeared that he was
not clearing his secretions. He was suctioned and we made
preparations to intubate him, however his sats were better. he
was [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 100322**] and sats were in the high 90s. He was
transferred to the unit for monitoring.
He had another epiode of desat and suctioning of a mucus plug in
the ICU. CXR showed. CXR [**5-14**] showed a L side white out. He as
intubated and bronched. There were thick copious secretions.
Patients family requested transfer to [**Hospital1 756**]:
Condition at discharge:
Neuro:intubated and sedated
Card: Amio gtt Dilt
Resp:On the vent
GI:NPO may have tube feeds PO
Hem;Stable
ID:vanc Ceftrioxone Flagyl; WBC 25
vasc: L toe infection and plan for a popliteal-posterior
tibialis bypass when medically stable
Endo: Insulin sliding scale
Prophylaxis: Protonix, SQH
Medications on Admission:
ASA 81mg' Calcium carbonate 1300', Digoxin 125mcg', Vitamin D
1000', Cyanocobalamin 100mcg', Diltiazem 180mg SR" , Lantus 64
units qam, Humulin SS qachs, vanco, Levaquin
Discharge Medications:
Acetaminophen Acetylcysteine 20% Albuterol 0.083% Neb Soln
Aspirin CeftriaXONE Digoxin Fentanyl Citrate Furosemide
Heparin Insulin
Magnesium Sulfate MetRONIDAZOLE (FLagyl) Paroxetine,
Perphenazine
Pantoprazole Quetiapine Fumarate Vancomycin
Midazolam gtt
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Peripheral vascular disease: needs popliteal-posterior tibialis
bypass
Cardiac: Recent NSTEMI; Cath 2 vessel disease
Respiratory : L Lung collapse s/p intubation and bronchoscopy
Discharge Condition:
Critical
Followup Instructions:
None
Completed by:[**2151-5-15**]
|
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icd9cm
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[]
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[
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[
[
[]
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7770, 7785
|
3913, 6948
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390, 1367
|
8008, 8018
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3480, 3601
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6963, 7257
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262, 352
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1395, 1878
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1900, 2476
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2508, 2601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,776
| 159,027
|
38218
|
Discharge summary
|
report
|
Admission Date: [**2105-6-8**] Discharge Date: [**2105-6-29**]
Date of Birth: [**2080-1-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
chest pain, hypertension
Major Surgical or Invasive Procedure:
esophagoduodenoscopy
cardiac catheterization
renal biopsy
History of Present Illness:
25 year-old W with PMHx of DM1 (Dx @ 15yo), HTN, chronic renal
insufficiency, and psoriasis, who was transferred from OSH for
evaluation of episodic chest pain X 2-4 months. The chest pain
is [**9-6**], left-sided, pressure-like, non-radiating that occurs
sporadically, with exertion or at rest, even awakening her from
sleep. It lasts for hours until alleviated by morphine or
dilaudid. It is associated with nausea and emesis, which
occasionally precede the chest pain. She has been evaluated
multiple times for this pain, and reports a history of 8 recent
hospital admissions with no conclusive diagnosis. She has been
treated for gastroparesis with no improvement in her chest pain.
According to prior notes, her pain was well controlled with
dilaudid as an outpatient; however, when this was abruptly
stopped the chest pains returned. She also notes that she
becomes hyperglycemic during these episodes despite taking her
insulin and not tolerating PO.
.
Of note, in [**2104-1-27**] the patient began to have "grand mal
seizures" which were diagnosed on clinical grounds and thought
to be due to hypoglycemic episodes at night. She had tonic
clonic movements and occassional loss of bladder and bowel
control. Her insulin regimen was changed, and the seizures
stopped in [**2104-9-28**]. She then began to have increasing
abdominal pain thought to be due to gastroparesis. In [**Month (only) 547**] of
[**2104**], she underwent laparoscopic cholecystectomy to treat her
gastroparesis. She developed psoriasis during the same month.
.
In the ED, initial vs were: T 99.1 P106 BP 192/104 R 20 O2 sat
100 RA. Patient was experiencing intermittant chest pain,
controlled with morphine PRN. Labs were notable for elevated
d-Dimer of 1059, creatinine 2.0, leukocytosis 17.2 and mild
anemia. EKG showed sinus tachycardia. She was initially
started on heparin gtt for suspicion of PE, but was found to
have guaiac + stools. NG withdrew coffee grounds, 250cc lavage
was clear with trace blood. Heparin gtt was stopped. EGD was
performed by GI and showed an esophageal ulcer and erosions in
the stomach and duodenum. The patient was started on a PPI. Her
Hct remained stable. Bilateral LE doppler's were negative for
DVT. Chest x-ray with no infiltrate, effusion or acute process.
Per report, CTA at OSH was negative.
.
In the ICU the patient developed chest pain, and was tachycardic
with blood pressures greater than 200/100. She was given IV
morphine and IV metoprolol, with improvement of BP to systolic
130s. Her pain improved, but was not alleviated. Her EKG was
unremarkable. Cardiac enzymes were sent and were negative for
ACS. TTE demonstrated EF 35-40%, and cardiolgoy was [**Year (4 digits) 4221**].
She had coronary catheterization which demonstrated no
hemodynamically significant lesions. She was stable and
transferred to the floor for further evaluation.
.
Past Medical History:
- Diabetes Mellitus Type 1
- Hypertension
- Renal Insufficiency secondary to diabetic nephropathy
- Gastroparesis
- Psoriasis
Social History:
Patient teaches pre-kindergarten. Lives at home with her parents
and younger siblings in [**Location (un) 7661**]. Moved back from NC recently.
Denies tobacco use, etoh and drugs/IVDU. Reports she feels safe
at home. Denies any recent family, work, or relationship stress.
Family History:
Mother: sickle cell trait
Father: Healthy
Maternal Grandmother: thyroid disease
Paternal Grandfather: diabetes type unknown, uses insulin
Brother: "some kind of Sickle cell disease"
Maternal uncle: died of "sickle cell" at age 42
Physical Exam:
GEN: well-developed, well-nourished female, lying comfortably in
bed, in no acute distress
HEENT: normocephalic, PERRL, EOMI, VFI, sclera aniceteric, pink
conjunctiva, MMM, oropharynx clear, no lymphadenopathy
CV: nl S1, S2, regular rhythm, increased rate, no murmurs, rubs,
gallops appreciated
Resp: CTAB without wheezes, crackles, or rhonchi
Abd: +BS, soft, non-tender, non-distended, no masses or
organomegaly
Ext: warm, well-perfused, psoriasis plaques on anterior shins,
2+ DP pulses
Neuro: A&OX3, CN 2-12 intact, [**Doctor First Name **] intact, [**4-1**] upper and lower
extremity strength, senstation grossly intact
Psych: appropriate mood and affect
Pertinent Results:
[**6-9**] TTEcho: global hypokinesis, EF 35-40%;
[**2105-6-29**] 06:01AM BLOOD WBC-8.6 RBC-2.70* Hgb-8.0* Hct-23.0*
MCV-85 MCH-29.7 MCHC-34.9 RDW-14.7 Plt Ct-353
[**2105-6-22**] 05:30AM BLOOD Neuts-62.7 Lymphs-31.7 Monos-4.2 Eos-1.3
Baso-0.2
[**2105-6-21**] 06:17AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Schisto-OCCASIONAL
[**2105-6-21**] 06:17AM BLOOD Hgb A-100 Hgb S-0 Hgb C-0
[**2105-6-21**] 06:17AM BLOOD Ret Aut-2.4
[**2105-6-29**] 06:01AM BLOOD Glucose-72 UreaN-28* Creat-1.7* Na-136
K-4.4 Cl-106 HCO3-26 AnGap-8
[**2105-6-21**] 06:17AM BLOOD LD(LDH)-219
[**2105-6-21**] 06:17AM BLOOD TotBili-0.1
[**2105-6-15**] 07:21PM BLOOD CK(CPK)-53
[**2105-6-8**] 04:20PM BLOOD ALT-13 AST-19 LD(LDH)-261* AlkPhos-90
TotBili-0.1
[**2105-6-8**] 04:20PM BLOOD Lipase-18
[**2105-6-15**] 07:21PM BLOOD CK-MB-2 cTropnT-<0.01
[**2105-6-9**] 12:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2105-6-8**] 11:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2105-6-29**] 06:01AM BLOOD Calcium-8.5 Phos-5.3* Mg-2.4
[**2105-6-21**] 06:17AM BLOOD Cryoglb-NEGATIVE
[**2105-6-21**] 06:17AM BLOOD Hapto-143
[**2105-6-12**] 01:00AM BLOOD calTIBC-157* Ferritn-139 TRF-121*
[**2105-6-8**] 05:37PM BLOOD D-Dimer-1059*
[**2105-6-9**] 12:50PM BLOOD %HbA1c-6.8* eAG-148*
[**2105-6-21**] 06:17AM BLOOD Triglyc-189* HDL-60 CHOL/HD-3.9
LDLcalc-134*
[**2105-6-10**] 05:18AM BLOOD TSH-5.8*
[**2105-6-10**] 05:18AM BLOOD Free T4-1.1
[**2105-6-23**] 08:01AM BLOOD Cortsol-1.3*
[**2105-6-21**] 06:17AM BLOOD HBsAg-NEGATIVE
[**2105-6-12**] 01:00AM BLOOD HBsAb-POSITIVE HAV Ab-NEGATIVE IgM
HBc-NEGATIVE
[**2105-6-9**] 12:50PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2105-6-22**] 05:30AM BLOOD IgA-244
[**2105-6-21**] 06:17AM BLOOD PEP-NO SPECIFI
[**2105-6-21**] 06:17AM BLOOD C3-124 C4-46*
[**2105-6-16**] 04:37AM BLOOD HIV Ab-NEGATIVE
[**2105-6-22**] 05:30AM BLOOD tTG-IgA-8
[**2105-6-12**] 01:00AM BLOOD HCV Ab-NEGATIVE
[**2105-6-21**] 06:17AM BLOOD ALDOSTERONE-Test
[**2105-6-21**] 06:17AM BLOOD RENIN-Test
[**2105-6-15**] 07:31PM BLOOD GASTRIN-Test
[**2105-6-9**] 12:50PM BLOOD Metanephrines (Plasma)-Test Name
[**2105-6-22**] 07:05PM URINE Blood-NEG Nitrite-NEG Protein-500
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM
[**2105-6-20**] 10:14AM URINE Eos-NEGATIVE
[**2105-6-20**] 09:23PM URINE Hours-RANDOM Creat-47 TotProt-532
Prot/Cr-11.3*
[**2105-6-20**] 09:23PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
[**2105-6-8**] 03:10PM URINE UCG-NEGATIVE
[**2105-6-20**] 05:14AM URINE 24Creat-943
[**2105-6-18**] 05:37PM URINE barbitr-NEG cocaine-NEG amphetm-NEG
[**2105-6-20**] 05:14AM URINE METANEPHRINES, FRACTIONATED, 24HR
URINE-Test
Brief Hospital Course:
# Episodes of chest pain, nausea & vomiting, tachycardia and
hypertension: these episodes are still of unclear etiology. A
number of services were [**Month/Day/Year 4221**] and testing performed, which
did not reveal a clear explaination. Only dilaudid reliably
relieved her pain, and only ativan relieved her nausea. Our best
guess is that these episodes are related to autonomic
dysfunction secondary to a history of brittle diabetes. We have
made an outpatient appointment for her with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who
is an autonomic specialist. Of note, pheochromocytoma was ruled
out by both plasma and urine metanephrine measures. At the time
of discharge the patient had not experienced one of these
episodes for at least 72 hours.
.
- Chest pain: The patient had a thorough work-up to ensure the
cause of her chest pain was not cardiac in nature. She was ruled
out for ACS and never had EKG changes. Her echo did show LV
dysfunction, which may be related to her elevated blood
pressures and tachycardia, as she had clean coronaries on
cardiac catheterization. The cardiology consult suggested a
number of labs looking for evidence of lyme, hemachromatosis,
HIV, and hepatitis, which were all negative. She was started on
a statin and an ACEI. She will need to follow up with Cardiology
as an outpatient. This appointment was made for her. The
patient's pain did not respond to nitroglycerin, nor a calcium
channel blocker so it is likely not secondary to esophageal or
coronary artery vasospasm. Her hemaglobin electrophoresis was
negative for sickle cell disease or trait. At discharge she was
given a prescription for a short course of PO dilaudid to
alleviate her chest pain until she follows up with her primary
care physician.
.
- Nausea/vomiting: The patient's nausea and vomiting is likely
secondary to gastroparesis and gastroesophgeal reflux.
Gastroenterology was [**Last Name (NamePattern1) 4221**] twice during her admission. She
received an EGD, which demonstrated esophagitis and
stomach/duodenal erosions, as well as a gastric emptying study
that showed gastroparesis. She was started on reglan, liquid
sucralfate, and a PPI. Her gastrin level was elevated, but not
extremely so and she had been on a PPI. She will need to follow
up with Gastroenterology as an outpatient. This appointment was
made for her. She had no neurologic deficits on exam, and an
opthalmoscopic exam was negative for papilledema. Records of
imaging studies from her OSH were negative for intracranial
abnormality one year ago. At discharge the patient was given a
short course of ativan to take when nauseated.
.
- Hypertension: The patient's blood pressure was elevated at
baseline, and would rise to systolic pressures in the 200s and
diastolic in the 100s during her episodes of pain. It was best
controlled on a combination of lisinopril, carvedilol, and a 0.1
mg clonidine patch.
.
- Tachycardia: The patient's baseline heart rate was in the mid
80s-90s. It would increase up to the 130s during her episodes of
pain, nausea and vomiting. Controlling her pain prevented her
heart rate from increasing.
.
# Diabetes mellitus I- Regular accuchecks were performed and the
patient was given basal lantus and sliding scale humalog as
needed. We [**Last Name (NamePattern1) 4221**] [**Last Name (un) **] for diabetes recomendations and
followed their daily suggestions. The patient will follow up
with [**Last Name (un) **] after discharge. We also made an appointment to for
her to have an ophthalmologic exam.
.
# Renal insufficiency: The patient exhibited significant
proteinuria on urinalysis with a Pr/Cr ratio of 11.3. Her
creatinine remained elevated around 1.8-2 and her outside
hospital records did not provide a reliable baseline. We
[**Last Name (un) 4221**] Renal, who suggested sending labs to rule out
secondary causes of hypertension (Renal U/S was negative for
renal artery stenosis, plasma renin and aldosterone levels were
normal, serum cortisol suppressed after dexamethasone), as well
as cryoglobulins (negative), SPEP/UPEP (negative), and
complement levels (normal). They performed a kidney biopsy,
which revealed diabetic nephropathy. We have set her up with a
follow up Renal appointment after discharge.
.
# Anemia: The patient's normocytic anemia is likely secondary to
her renal disease. Her hematocrit remained stable throughout her
hospital stay. Evaluation for hemolysis was negative. She will
need to follow up with her primary care physician for continued
evaluation and monitoring.
.
# Prophylaxis: The patient was maintained on SC heparin for DVT
prophylaxis until she received the kidney biopsy, and was
switched to pneumoboots.
Medications on Admission:
Insulin
Clobetasol
Metoprolol
Lisinopril
Elavil
Ultram
Lyrica
Nortryptiline
Coreg
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Please take 30 minutes prior to eating.
Disp:*90 Tablet(s)* Refills:*2*
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
6. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 2 weeks.
Disp:*84 Tablet(s)* Refills:*0*
7. Sucralfate 100 mg/mL Suspension Sig: Ten (10) ML PO QID (4
times a day): Please take 10 mL by mouth one hour before meals,
and at bedtime. Please do not take with other medications. .
Disp:*1200 ML(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week: please place every Saturday.
Disp:*5 patches* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) Units
Subcutaneous once a day: in AM.
Disp:*1 bottle* Refills:*2*
11. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: Please take as prescribed. Please
check your blood sugar before meals and before bedtime. Please
take the number of units corresponding to the insulin sliding
scale that you were provided.
Disp:*1 bottle* Refills:*2*
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea: please place under tongue as needed
for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Autonomic hypereflexia
Gastroesophageal Reflux Disease
Gastroparesis
Diabetes Mellitus, insulin-dependent
Chronic Kidney Disease secondary to diabetic nephropathy
Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were recently admitted to [**Hospital1 1170**] for evaluation of your chest pain, which is accompanied
by nausea and vomiting, and increased blood pressure and heart
rate. We have ran many tests and [**Hospital1 4221**] many specialists, but
are unable to fully understand why you have these episodes. We
suspect it is the result of your nerves reacting too strongly to
different stimuli. During your hospital stay we obtained a
gastric emptying study, which showed that you have
gastroparesis, meaning that your stomach does not move its
contents down at a normal rate. This is due to your diabetes and
causes nausea, vomiting, and pain. It may then lead to your body
reacting to the pain, nausea, and vomiting with increased heart
rate and blood pressure. We have given you a medication called
Reglan to take 30 minutes prior to meals to help with the
gastroparesis. We have also started you on medications to
control your blood pressure and heart rate.
Importantly, during your stay we determined that your chest pain
was NOT from a blood clot in an artery of your lung, or a heart
attack. Gastroenterology doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**] and [**Name5 (PTitle) **] ulcers
in your esophagus, stomach, and part of your intestine, for
which you were started on medications. Cardiology doctors were
also [**Name5 (PTitle) 4221**] and saw on an echocardiogram that your heart is
not pumping as strong as it should be. You underwent cardiac
catheterization and they saw no blockages in your coronary
arteries. We also [**Name5 (PTitle) 4221**] the Kidney doctors, who performed a
biopsy of your kidney, which told us that your kidney problems
are the result of your diabetes. The [**Last Name (un) **] Diabetes doctors
were [**Name5 (PTitle) 4221**] and [**Name5 (PTitle) 20554**] us daily recommendations on how to best
control your diabetes.
Throughout the hospital course we controlled your blood
pressure, heart rate, nausea and pain with both intravenous and
oral medications. You are doing well on oral medications now.
You will need to follow up with a primary care doctor, and many
specialists, for continued evaluation of your symptoms. We have
made you appointments to follow up with these services:
Gastroenterology
Cardiology
Renal (Kidney)
Neurology
Primary Care Physician
[**Name Initial (PRE) 6091**]
Please stop taking all the medications you were taking prior to
coming to the hospital. You were provided prescriptions for all
of your new medications. Please take them as prescribed.
Followup Instructions:
Primary Care Physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] ([**Telephone/Fax (1) 66039**]) Great
[**Hospital1 487**] Family Alliance Center
[**2105-7-7**] at 13:45 pm
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2105-7-8**] at 10:40 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2105-7-8**] at 12:00 PM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2105-7-20**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2105-8-6**] at 12:00 PM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Name: [**Last Name (LF) **], [**First Name3 (LF) 33664**] T. MD
Location: [**Last Name (un) **] DIABETES CENTER/ OPHTHALMOLOGY
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: [**Last Name (LF) 2974**], [**7-10**], 4PM
Department: NEUROLOGY
When: THURSDAY [**2105-8-27**] at 3:30 PM
With: DRS. [**Name5 (PTitle) 4777**] & [**Last Name (un) **] [**Telephone/Fax (1) 8139**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"536.3",
"428.0",
"403.90",
"696.1",
"584.9",
"583.81",
"531.40",
"337.9",
"V58.67",
"250.43",
"532.40",
"530.81",
"250.63",
"530.21",
"425.4",
"428.22",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"38.93",
"88.53",
"88.56",
"37.22",
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
14052, 14058
|
7345, 12048
|
329, 389
|
14275, 14275
|
4681, 7322
|
17022, 19269
|
3756, 3987
|
12180, 14029
|
14079, 14254
|
12074, 12157
|
14426, 16999
|
4002, 4662
|
265, 291
|
417, 3299
|
14290, 14402
|
3321, 3449
|
3465, 3740
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,233
| 168,480
|
19279+57036
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-9-19**] Discharge Date: [**2194-9-24**]
Date of Birth: [**2117-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
Coronary Artery Bypass grafts x 4(Left Internal Mammary
Artery->Left Anterior Descending ,Saphenous Vein Grafted
->Obtuse Marginal ,Saphenous Vein Grafted -Posterior Descending
Artery ,Y-PLV)[**2194-9-19**]
History of Present Illness:
This 76 year old white male has known coronary artery disease
for years. He recently developed dizziness. A mass at the base
of his tongue was noted and cardiology clearance was requested.
This led to a stress test and subsequent cath, demonstrating
triple vessel disease and preserved LV function of 58%. There
is evidence of diastolic dysfunction. He was referred for
surgery.
Past Medical History:
Chronic Diastolic Congestive Heart Failure
Coronary Artery Disease
Chronic Atrial Fibrillation
Hypertension
Dyslipidemia
Diabetes Mellitus
Chronic obstructive pulmonary disease
Peripheral Vascular Disease
mass at base tongue
s/p cataract extraction and intraocular lens implants
Vertigo/Dizziness
Pericardiocentesis for Pericardial Tamponade [**2184**]
s/p right leg Bypass (Popliteal to DP)
s/p Left Leg angioplasty and Stenting
s/p Toe Amputation x 2
s/p Pituitary Tumor Removal [**2184**]
Social History:
retired, lives with his wife
[**Name (NI) 4084**] smoked, denies ETOH use
Family History:
noncontributory
Physical Exam:
Admission:
Pulse: 76 O2 sat: 97%
B/P Right: 150/74 Left: 158/70
Height: 6'3" Weight: 240lbs
General: Well-developed, well-nourished male using wheel-chair
d/t difficulting ambulating. Pt. able to walk be unstable d/t
dizziness/vertigo.
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema: 1+ Varicosities:
None, Healed incision on right calf (from knee to ankle)
Neuro: Intact, [**3-25**] strengths, difficulty ambulating
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 0-1+ Left: 1+
PT [**Name (NI) 167**]: 0-1+ Left: 0-1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: none
Pertinent Results:
[**2194-9-21**] 05:20AM BLOOD WBC-14.8* RBC-3.37* Hgb-10.2* Hct-29.6*
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.7 Plt Ct-155
[**2194-9-20**] 03:56AM BLOOD WBC-16.3* RBC-3.67* Hgb-11.1* Hct-32.1*
MCV-88 MCH-30.2 MCHC-34.6 RDW-14.6 Plt Ct-176
[**2194-9-21**] 05:20AM BLOOD Glucose-185* UreaN-22* Creat-0.9 Na-139
K-4.9 Cl-104 HCO3-26 AnGap-14
[**2194-9-20**] 03:56AM BLOOD Glucose-102 UreaN-15 Creat-0.8 Na-139
K-4.4 Cl-108 HCO3-27 AnGap-8
[**2194-9-21**] 05:20AM BLOOD Mg-2.3
[**2194-9-23**] 05:30AM BLOOD WBC-11.6* RBC-3.22* Hgb-9.6* Hct-28.0*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.8 Plt Ct-252
[**2194-9-23**] 05:30AM BLOOD Glucose-149* UreaN-25* Creat-0.8 Na-137
K-4.2 Cl-101 HCO3-27 AnGap-13
Brief Hospital Course:
[**9-19**] Mr.[**Known lastname 16905**] was taken to the operating room and underwent
Coronary Artery Bypass grafts x 4(Left Internal Mammary
Artery->Left Anterior Descending ,Saphenous Vein Grafted
->Obtuse Marginal ,Saphenous Vein Grafted -Posterior Descending
Artery ,Y-PLV)with Dr.[**First Name (STitle) **]. Cross clamp time=94 minutes.
Cardiopulmonary bypass time=132 minutes. Please refer to
Dr[**Doctor First Name **] operative report for further details. He was
transferred to the CVICU intubated, sedated,in critical but
stable condition. He awoke neurologically intact and was
extubated without difficulty. Beta blockade,statin, aspirin,
and diuresis was initiated. All lines and drains were
discontinued in a timely fashion. POD#1 he was transferred to
the step down unit for further monitoring. Physical Therapy was
consulted for evaluation of mobilization and strengthening.
Postoperatively he remained in his chronic atrial fibrillation
and Beta-Blockade was optimized to control the ventricular
response. He refuses, as in the past, to take
Coumadin/anticoagulation despite the risks of potential
thrombus/emboli associated with atrial fibrillation. Temporary
pacing wires were removed on POD 3. On [**9-22**] he agreed to
allow ENT to biopsy his tongue mass and consult was requested.
Prior biopsy with ultrasound guidance of the right neck nodes
was reportedly negative for malignancy. Upon ENT's arrival,
however, Mr.[**Known lastname 16905**] then refused the biopsy. The remainder of
his postoperative course was essentially uneventful. He
continued to progress and Physical therapy recommended PT at
home. On POD#5 he was cleared by Dr.[**First Name (STitle) **] for discharge to
home. All follow up appointments were advised.
Medications on Admission:
Androderm
Aspirin 325mg/D
Atenolol 50mg/D
Atrovent MDI
Lantus Insulin 75units Qam, 25units Q pm
Lasix 80mg/D
Lisinopril 40mg/D
Neurontin 300mg [**Hospital1 **]
Omeprazole 20mg/D
Zocor 20mg/D
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): twice daily x 10 days, then once daily ongoing.
Disp:*120 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO Q12H
(every 12 hours): twice daily x 10 days, then once daily.
Disp:*120 Packet(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Cartridge Sig: One (1)
Subcutaneous once a day: 75 units each AM-resume home dosing .
Disp:*qs * Refills:*2*
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed: resume home dosing.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hypertension
mass at base of tongue
Chronic Diastolic Congestive Heart Failure
Chronic Atrial Fibrillation
Dyslipidemia
s/p Cataract extraction and intraocular lens implants
Vertigo/Dizziness
Pericardiocentesis for Pericardial Tamponade [**2184**]
s/p right leg Bypass (Popliteal to DP)
s/p Left Leg angioplasty and Stenting
s/p toe Amputations
s/p Pituitary Tumor Removal [**2184**]
Discharge Condition:
A&Ox3, ambulates with walker (preoperative condition),doing
well
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] [**Name (STitle) **] Reddi in [**11-22**] weeks ([**Telephone/Fax (1) 41901**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] In 2 weeks
Dr. [**Last Name (STitle) **] as directed for tongue mass
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2194-9-24**] Name: [**Known lastname 9769**],[**Known firstname 3458**] Unit No: [**Numeric Identifier 9770**]
Admission Date: [**2194-9-19**] Discharge Date: [**2194-9-24**]
Date of Birth: [**2117-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 265**]
Addendum:
Discharge dosage of Simvastatin increased to 80 mg po
daily-resumed home dosage.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 1066**], [**First Name3 (LF) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2194-9-24**]
|
[
"250.00",
"272.4",
"428.32",
"427.31",
"401.9",
"414.01",
"V58.66",
"496",
"443.9",
"784.2",
"428.0",
"423.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8577, 8778
|
3155, 4909
|
310, 519
|
7136, 7204
|
2450, 3132
|
7608, 8554
|
1553, 1570
|
5151, 6544
|
6671, 7115
|
4935, 5128
|
7228, 7585
|
1585, 2431
|
247, 272
|
547, 930
|
952, 1446
|
1462, 1537
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,847
| 178,850
|
5667+5668+5669
|
Discharge summary
|
report+report+report
|
Admission Date: [**2201-2-28**] Discharge Date: [**2201-3-9**]
Date of Birth: Sex: F
Service: Medicine, [**Location (un) **] Firm
NOTE: The day of discharge to be dictated in an Addendum.
This is a dictation up to [**2201-3-8**].
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old
female with a history of human immunodeficiency virus, and
hepatitis C virus, and liver cirrhosis who came to [**Hospital1 1444**] Emergency Department
complaining of increasing fatigue and icterus.
The patient was also complaining of weakness, lethargy, sore
throat, and hoarseness. She had an episode of epistaxis
earlier on the morning of admission. The patient denies
fevers or chills. She complains of hoarseness and a sore
throat. The symptoms started two weeks ago with nonspecific
joint/muscle pain, increasing pruritus, fatigue, and
weakness. The patient is also complaining of a cough
productive of [**Doctor Last Name 352**] phlegm and no blood as well as occasional
shortness of breath. The symptoms have been worsening over
the past one week. The patient denies any abdominal pain.
She has no history of weight loss or weight gain. No
diarrhea. No headache. No sick contacts. [**Name (NI) **] travel. The
patient has been on prednisone for a history of hemolytic
anemia. The prednisone was stopped in [**2201-1-4**] after
a taper since smear looked okay and there was no evidence of
hemolysis by DAT test.
In the Emergency Department, the patient had a hematocrit of
24.4. The patient had a right upper quadrant ultrasound
which showed improving ascites. No common bile duct
dilatation. A chest x-ray showed no evidence of pneumonia.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus; the patient is off
antiretroviral medications since [**2200-3-4**]. Trizivir was
stopped secondary to cirrhosis. The patient's viral load was
greater than 100,000 in [**2200-6-3**]. The patient's CD4
count was greater than 800 just recently.
2. Hepatitis C virus and cirrhosis; the patient was
recently discharged from [**Hospital1 69**]
in [**2200-12-4**] with ascites. The patient is status post
interferon and ribavirin therapy which were discontinued in
[**2200-3-4**].
3. History of autoimmune hemolytic anemia; question
secondary to interferon and ribavirin versus secondary to
immune dysregulation due to hepatitis C virus and human
immunodeficiency virus. The patient has been on chronic
steroids 5 mg by mouth every day of prednisone; however,
steroids were stopped in [**2200-12-4**] because there was no
evidence of hemolytic anemia by the patient's hematologist
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22656**].
4. History of acute renal failure.
5. History of Tylenol toxicity; accidental.
6. History of pancreatitis in [**2200-3-4**].
7. History of cellulitis in [**2200-3-4**].
8. History of a gastrointestinal bleed from an esophageal
varices in [**2200-3-4**].
9. History of [**Known lastname **] cyst rupture in [**2200-3-4**].
10. Depression.
11. Hypercholesterolemia.
12. History of bullous impetigo.
13. History of Clostridium difficile colitis.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg by mouth once per day.
2. Bactrim double strength (questionable whether patient was
taking this or whether that was supposed to be discontinued).
3. Citalopram 20 mg by mouth once per day.
4. Lactulose 30 mg by mouth three times per day.
5. Nystatin swish-and-swallow.
6. Lasix 40 mg by mouth once per day.
7. Aldactone 100 mg by mouth once per day.
8. Hydroxyzine 25 mg to 50 mg by mouth q.6h. (for pruritus).
9. Sarna lotion.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married but separated. She
lives alone. She has a dog and a cat. She has children.
Positive tobacco of four to five cigarettes per day.
Positive alcohol use of one to two glasses of wine per day.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.9
degrees Fahrenheit, her blood pressure was 110/60, her pulse
was 82, her respiratory rate was 18, and her oxygen
saturation was 97% on room air. Generally, the patient was
sitting up in bed with a hoarse voice. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light and accommodation. The
extraocular muscles were intact. The mucous membranes were
moist. The neck revealed a clear-based shallow ulceration on
the posterior neck with erythematous borders. There was no
lymphadenopathy. The patient had hypopigmented lesions on
her upper back that were similar in shape to a clear-based
ulceration. Pulmonary examination revealed the lungs were
clear to auscultation bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. There were no murmurs,
rubs, or gallops. The abdomen revealed positive bowel
sounds. Somewhat tense, but not tender, and slightly
distended. Extremity examination revealed no cyanosis,
clubbing, or edema. Pretibial area revealed palpable
pruritic nodules on the left and right tibial surface that
were painful. There were no petechiae.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 18.4, her hematocrit was 24.2, and her
platelets were 88. Differential with neutrophils of 86,
lymphocytes of 10.3, monocytes of 3.1, and eosinophils of
0.2. Her INR was 1.7, her prothrombin time was 16, and her
partial thromboplastin time was 31.2. Free calcium was 1.07.
Blood cultures and urine cultures revealed no growth to date.
CD4 count was [**Numeric Identifier 22660**]. The patient's initial creatinine on
presentation was 1.2.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed patchy
atelectasis at the bases and low lung volumes.
A right upper quadrant ultrasound showed gallstones; stable
from prior. There was decreased gallbladder wall edema.
Decreasing ascites; a very small amount. A fatty liver. No
ductal dilatation. Normal common bile duct. Normal hepatic
vein.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. ANEMIA ISSUES: This was likely anemia of chronic disease
as was evidenced by iron studies. The patient's peripheral
blood smear was initially reviewed with a hematologist.
There was no evidence of hemolysis by either looking at the
smear or by laboratories. The patient's initial fibrinogen
was normal. Her haptoglobin was normal, and DAT test was
negative. The patient initially received 1 unit of packed
red blood cells to increase caudate pressure in the setting
of acute-on-chronic renal failure. The patient was started
on iron, ascorbic acid, and Epogen.
2. INFECTIOUS DISEASE ISSUES: The patient grew out
gram-positive cocci in pairs and clusters, further identified
as methicillin-resistant Staphylococcus aureus in one of the
blood cultures. The patient was subsequently started on
vancomycin. The patient was also started on ciprofloxacin
for a presumed urinary tract infection.
The patient had a transthoracic echocardiogram which was
negative for endocarditis.
The patient was planned to undergo a bone scan to rule out
osteomyelitis of the neck which was pending at the time of
this dictation. The patient did not have any abdominal
tenderness, and a paracentesis was attempted to rule out
spontaneous bacterial peritonitis; however, no peritoneal
fluid was obtained even after an ultrasound-guided marking.
The patient was planned to undergo and ultrasound-guided
paracentesis the following morning.
3. CHRONIC LIVER DISEASE ISSUES: The patient definitely
showed signs of decompensation; especially in the setting of
a combination of worsening liver disease and acute-on-chronic
renal failure. The patient's hepatitis C viral load was
checked and was greater than 700,000. In the setting of
acute renal failure, Lasix and Aldactone were held. Bactrim
was stopped the day after admission. The patient was started
on nadolol 400 mg by mouth once per day to prevent upper
gastrointestinal bleeding from esophageal varices since the
patient had an episode of prior in the past.
The Hepatology Service was consulted since after restarting a
very low dose of Lasix and Aldactone the patient went into
rapidly progressive acute renal failure despite continued
hydration and blood transfusion for caudate pressure
increase. The patient was likely rapidly progressing into
decompensated liver failure, and Hepatology recommendations
were pending.
4. ACUTE RENAL FAILURE ISSUES: The patient initially came
in with a creatinine of 1.2; however, her creatinine
increased to 1.5 and to greater than 2 the day following
admission. This was thought to be multifactorial in the
setting of dehydration, bacteremia, using nonsteroidal
antiinflammatory drugs at home, and being started on Bactrim.
The patient's diuretics were held and intravenous fluids were
administered. The patient's sediment was benign without any
evidence of proteinuria or hematuria. There were no casts.
The patient's fractional excretion of sodium was less than
0.1%. The patient's renal ultrasound showed bilaterally
small kidneys, cortical thinning, and medullary
nephrocalcinosis.
The patient was seen by the Renal Service in consultation who
thought that they etiology of the patient's acute-on-chronic
renal failure was likely multifactorial. They entertained an
idea of human immunodeficiency virus nephropathy as an
underlying etiology of the patient's renal failure; however,
this was somewhat atypical with the absence of proteinuria.
The patient's creatinine initially improved after 2 units of
packed red blood cells; however, after re-administration of a
very low dose of Lasix and Aldactone the patient's creatinine
worsened again. The patient showed signs of fluid retention
concerning for hepatorenal syndrome. Diuretics were held. A
Renal consultation was obtained again.
5. MENTAL STATUS CHANGE ISSUES: The patient was getting
increasingly agitated and intermittently confused. An
ammonia level was checked and was only 19. The patient was
also developing progressive thrombocytopenia. The patient
has a history of thrombocytopenia in the setting of
hypersplenism; however, the patient's platelets went from 100
to 50/60. This constellation of findings was definitely
concerning for the possibility of thrombotic thrombocytopenic
purpura/hemolytic uremic syndrome. Once again, the
recommendations from the Renal Service were pending. Smear
review was also pending at this time.
6. THROMBOCYTOPENIA ISSUES: As above, the differential
diagnosis included splenic sequestration, acute decrease in
platelets secondary to bacteremia, the possibility of
heparin-induced thrombocytopenia, heparin-dependent
antibodies were sent and all heparin flushes were stopped, or
the possibility of a more serious diagnosis such at
thrombotic thrombocytopenic purpura/hemolytic uremic
syndrome. All of the above etiologies are currently worked
up.
NOTE: This Discharge Summary is to be followed by an
Addendum dictated by the physician who is taking over my
service.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2201-3-9**] 14:30
T: [**2201-3-13**] 08:23
JOB#: [**Job Number 22661**]
Admission Date: [**2201-3-9**] Discharge Date: [**2201-4-5**]
Date of Birth: Sex: F
Service:
ADDENDUM: This Discharge Summary will span the dates of [**2201-3-9**] through [**2201-4-5**].
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED):
1. ACUTE RENAL FAILURE ISSUES: The patient was seen in
consultation by both the Liver and Renal teams. The Liver
team did not feel that her acute renal failure was consistent
with hepatorenal syndrome. There was not a clear diagnosis
for the renal failure; however, her renal function continued
to rapidly decline with a rise in creatinine and a decreasing
urine output.
With the patient approaching anuric renal failure, and no
clear diagnosis, the patient was sent for a renal biopsy.
The biopsy was complicated by the development of a
perinephric hematoma in the setting of her coagulopathy, felt
to be secondary to her liver disease. The perinephric
hematoma was followed with serial ultrasounds and remained
stable throughout her course.
The biopsy results from the kidney revealed acute tubular
necrosis. There were also some changes consistent with
chronic microangiopathic thrombotic changes as well as a
suggestion of membranoproliferative glomerulonephritis;
although, the Renal team was not impressed with either of
these possibilities.
Ultimately, the patient was forced to be started on
hemodialysis for the implication of fluid overload in the
setting of worsening hypoxia. Subsequent to starting
hemodialysis, the patient underwent a difficult and
complicated course that will be described in more detail
below; including further episodes of hypotension and the need
for contrast administration. Ultimately, her kidney function
did not seem to be responding, and she was continued on three
times per week hemodialysis intermittently with extra
sessions of ultrafiltration for volume issues.
At the time of this dictation, the patient was still
maintained on hemodialysis with no indication of renal
recovery.
2. PULMONARY ISSUES: The patient's initial complaints did
not include many respiratory symptoms; although, she did
complain of a mild cough as well as a hoarse voice and sore
throat.
Incidentally, on a chest x-ray for a peripherally inserted
central catheter line placement, there was noted to be
bilateral interstitial infiltrates. It was felt that these
could be consistent with a diagnosis of Pneumocystis carinii
pneumonia; although, the patient's CD4 count was intact.
The patient was set to undergo an induced sputum, but prior
to that felt volume overload from her aforementioned renal
failure. This episodes of hypoxia from volume overload in
the setting of the perinephric hematoma (as described above)
status post biopsy, as well as a drop in her hematocrit,
resulted in transfer to the Medical Intensive Care Unit.
In the Medical Intensive Care Unit, the patient underwent a
bronchoscopy where her bronchoalveolar lavage culture data
was all negative; including negative for Pneumocystis carinii
pneumonia. Although there was a portion of lung disease
secondary to volume overload, due to renal failure, there was
evidence that these interstitial infiltrates were worsening
on follow-up imaging; including a computed tomography of the
chest.
Without a clear diagnosis, the patient was treated
supportively, avoiding intubation, and was eventually
transferred back out to the floor. This was approximately on
[**3-22**]. That same day, the patient's cytology from her
bronchoscopy revealed suspicion for bronchoalveolar
carcinoma.
Due to this, and the still unclear diagnosis of the pulmonary
process, the patient underwent a video-assisted thoracic
surgery procedure and biopsy.
On the day following the video-assisted thoracic surgery (on
[**3-23**]), the patient had an acute episode of hypoxia.
Again, there was no clear etiology for this acute change.
She was taken hemodialysis with the thought that pulmonary
edema was contributing.
Over the next few days, she became hypotensive to the 70s
systolic and was febrile. She was treated for a possible
hospital-acquired pneumonia and underwent lower extremity
noninvasive studies which were negative for deep venous
thrombosis.
Her pulmonary status remained relatively stable with a slowly
reducing oxygen requirement until the morning of [**3-27**]
when the patient had a second episode of acute hypoxia
requiring a second transfer to the Medical Intensive Care
Unit. This time requiring intubation. The lung biopsy
finally revealed no infection, and rather a diagnosis of
bronchiolitis obliterans-organizing pneumonia.
Thus, the patient was treated with intravenous steroids. The
patient was eventually extubated on [**4-3**] and was
transferred back to regular floor on [**4-5**] on supplemental
oxygen.
3. LIVER ISSUES: The patient has hepatitis C and cirrhosis.
Initially, the Hepatology team was following due to renal
failure as well as worsening encephalopathy. At that time,
they felt that her liver disease, although significant, was
not playing a significant role in the renal failure, and her
encephalopathy was likely multifactorial.
Following her first Medical Intensive Care Unit course, and
prior to her second, there was evidence of worsening liver
function; including an elevated INR above her baseline and
worsening total bilirubin up to the 8s. Again, the Liver
team was consulted and they felt that her decompensating
liver failure was again secondary to her overall condition
and her overall active comorbidities.
4. THROMBOCYTOPENIA ISSUES: The patient is thrombocytopenic
at baseline, but had a worsening of her platelet count. A
heparin-induced thrombocytopenia antibody test was sent, and
this came back positive. All heparin was stopped, and there
was no evidence of thrombotic complications.
The Hematology Service was consulted to help with the
thrombocytopenia as well as to rule out thrombotic
thrombocytopenic purpura, as the patient also had renal
failure, change in mental status, and possibly hemolytic
anemia.
The Hematology Service did not believe that thrombotic
thrombocytopenic purpura was playing a role and felt that the
thrombocytopenia was multifactorial; including acute
infection, heparin-induced thrombocytopenia, and chronic
sequestration.
5. MENTAL STATUS CHANGES: As noted above, the patient's
worsening mental status and asterixis were felt to be of
multifactorial origin; likely a metabolic encephalopathy due
to her many active problems. There was a correlation between
her mental status and her overall medical condition, as she
would become more confused and encephalopathic when she was
more ill.
6. GASTROINTESTINAL BLEED ISSUES: While in the Medical
Intensive Care Unit, the patient had an upper
gastrointestinal bleed. An endoscopy was performed which
revealed portal gastropathy and no esophageal varices. The
patient received one unit of packed red blood cells for this
acute blood loss but was stable thereafter. The patient was
started back on nadolol for a decrease in the portal
pressures.
7. COLITIS ISSUES: The patient underwent a computed
tomography scan of the abdomen which revealed evidence of a
colitis. All Clostridium difficile toxins had been negative.
At the time of this dictation, the patient had a D-toxin
assay sent which was pending. The patient was treated
empirically with Flagyl.
She had diarrhea on and off throughout her course; although
she is being treated with lactulose for encephalopathy, so it
was difficult to determine the cause.
8. PANCREATITIS ISSUES: There was an elevated amylase and
lipase. It was felt this could be a chemical pancreatitis
due to medications (possibly Flagyl) or possibly due to
infection.
There was no clinical signs or symptoms, she was treated
supportively and followed.
NOTE: This hospital summary is through [**2201-4-5**]. The
remainder of the hospital course, including the discharge
diagnoses, and discharge medications will be dictated as part
of an Addendum to this Discharge Summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2201-4-7**] 19:41
T: [**2201-4-7**] 19:49
JOB#: [**Job Number 22662**]
Admission Date: [**2201-2-28**] Discharge Date: [**2201-4-25**]
Date of Birth: [**2159-10-27**] Sex: F
Service: MED
This dictation will cover the [**Hospital 228**] hospital course from
[**2201-4-7**] until [**2201-4-25**]. Please refer to previous
dictation done by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] for details of [**Hospital 228**]
hospital course.
HOSPITAL COURSE: (By systems-continued)
Acute renal failure - As noted in previous discharge summary,
the patient continued on hemodialysis for worsening renal
function secondary to acute tubular necrosis.
Pulmonary issues - As noted on previous discharge summary the
patient was transferred back to the regular medical floor on
[**4-5**], on supplemental oxygen. He remained on treatment with
steroids for bronchiolitis obliterans-organizing pneumonia.
The patient also continued on Cefepime for ventilator-
associated pneumonia that she developed during her Intensive
Care Unit stay. On [**4-8**], the patient developed a
pneumothorax. High-flow oxygen was administered. On [**4-12**],
the patient had desaturated and experienced worsening
shortness of breath following an episode of emesis. The
patient was transferred back to the Medical Intensive Care
Unit where she was treated for aspiration pneumonitis with
Vancomycin and Zosyn. The patient remained in the Intensive
Care Unit for a few days and then was transferred back to the
medical floor. She was maintained on 2 liters nasal cannula
oxygen. A week later, however, the patient developed
worsening hypoxia and respiratory failure. The patient was
transferred back to the Medicine Intensive Care Unit for
further management. Given the patient's persistent hypoxia,
she required reintubation on [**4-23**]. The patient underwent
bronchoalveolar lavage on that day. Respiratory culture
revealed moderate growth of yeast. This was confirmed in
fungal cultures as well. Tests for Pneumocystis carinii
pneumonia were negative. Per Infectious Disease, the patient
was started on Caspofungin for treatment of the yeast in her
bronchoalveolar lavage. As noted in previous discharge
summaries, the patient also required administration of
Caspofungin for treatment of Candidemia. By [**4-25**], the
patient's family noted that Ms. [**Known lastname **] did not want to remain
on the ventilator. Since the patient's respiratory status
continued to decline, the patient was extubated on [**4-25**],
and made Comfort-Measures-Only. The patient expired on the
evening of [**4-25**].
Infectious disease issues - As noted above, the patient was
noted to grow yeast from her bronchoalveolar lavage cultures
and her blood cultures were also positive for Candidemia and
Vancomycin-resistant Enterococcus. Infectious disease
consultation was obtained regarding treatment of these
infections. Given the patient's immunocompromised status and
disseminated fungal infection, the family decided to withdraw
care on [**4-25**], in accordance with the patient's wishes.
The patient expired on [**2201-4-25**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 6327**]
Dictated By:[**Doctor Last Name 22663**]
MEDQUIST36
D: [**2201-5-2**] 18:35:32
T: [**2201-5-2**] 20:28:33
Job#: [**Job Number 22664**]
|
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,786
| 151,566
|
7647
|
Discharge summary
|
report
|
Admission Date: [**2173-4-9**] Discharge Date: [**2173-4-17**]
Date of Birth: [**2107-8-29**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation/Extubation
Left IJ Central Line
History of Present Illness:
This is a 65-year-old woman with a history of depression,
backpain, asthma presents with altered mental status and
hypercarbic respiratory failure.
Per patient's husband, over the last several days she has been
feeling "shaky" and weak. Yesterday, her husband noted she was
confued and making nonsensical statements. She also had poor
coordination, had tremors and was dropping things at home. Had
two falls, no head injury, no LOC. Husband noted she was
sweaty, had a prodcutive cough. Also noted recently increased
paxil dose from 20mg to 40mg. Her husband took her to the
[**Hospital3 17031**].
.
Patient presented to OSH where she was noted to be latharrgic
and confused. VS there were T 99.0, HR 102, SpO2 86% on RA.
Concerned for opioid overdose, given narcan woke up but O2 sat
in 70s, agitated, given ativan, morphine. Head CT negative. BNP
329. TropI 0.36. Tox screen negative. D-dimer negative. CXR ?
PNA. Intubated for hypoxia. Given 325mg of ASA. Transferred to
[**Hospital1 18**] for further management.
.
On arrival, VS HR 66, BP 142/126, RR 27, 100/vent. Started
propofol, and patient became transiently hypotensive to 82/52.
EKG showed NSR, rate 70, q waves in II, III, aVF, no STTW
changes. CXR showed ? LLL PNA. Given vanc 1g IV, zosyn 4.5g IV
x 1.
.
On transfer VS were HR 64 100/61 16 100/ vent AC FiO2 50, Tv
500, PEEP 5, RR 16. On arrival to the ICU, patient was
intubated and sedated.
Past Medical History:
- Depressive Disorder
- Back Pain
- Asthma
- Hypothyroidism
- Anxiety
- Multiple prior back surgeries
- palate shave for sleep apnea x 2
- h/o CCY
Social History:
Retired nurse, married, husband very ill with multiple myeloma.
Family History:
Mother died of breast CA at 66. Father died of lymphoma, "heart
issues" at 90.
Physical Exam:
VS: Temp: BP: 162/81 HR: 76 RR: O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
Admission Labs:
[**2173-4-9**] 07:35PM CK(CPK)-310*
[**2173-4-9**] 07:35PM CK-MB-8 cTropnT-0.04*
[**2173-4-9**] 11:40AM LACTATE-1.3
[**2173-4-9**] 11:36AM GLUCOSE-115* UREA N-33* CREAT-1.5* SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2173-4-9**] 11:36AM ALT(SGPT)-148* AST(SGOT)-162* LD(LDH)-292*
CK(CPK)-406* ALK PHOS-129* AMYLASE-61 TOT BILI-0.6
[**2173-4-9**] 11:36AM LIPASE-43
[**2173-4-9**] 11:36AM CK-MB-10 MB INDX-2.5
[**2173-4-9**] 11:36AM cTropnT-0.09*
[**2173-4-9**] 11:36AM ALBUMIN-3.6
[**2173-4-9**] 11:36AM TSH-12*
[**2173-4-9**] 11:36AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2173-4-9**] 11:36AM WBC-9.6 RBC-3.55* HGB-11.4* HCT-34.3* MCV-97
MCH-32.2* MCHC-33.4 RDW-12.6
[**2173-4-9**] 11:15AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-POS mthdone-POS
[**2173-4-10**] 04:07AM BLOOD Free T4-0.66*
Discharge Labs:
[**2173-4-16**] 05:35AM BLOOD WBC-10.9 RBC-3.98* Hgb-12.4 Hct-38.0
MCV-95 MCH-31.3 MCHC-32.8 RDW-12.9 Plt Ct-290
[**2173-4-10**] 04:07AM BLOOD Neuts-80.5* Lymphs-12.2* Monos-6.1
Eos-0.7 Baso-0.4
[**2173-4-16**] 05:35AM BLOOD Glucose-82 UreaN-13 Creat-1.1 Na-143
K-3.9 Cl-99 HCO3-36* AnGap-12
[**2173-4-14**] 05:50AM BLOOD ALT-87* AST-32 CK(CPK)-86 AlkPhos-95
TotBili-0.3
Imaging:
[**4-9**]: CXR:
IMPRESSION: Small left pleural effusion. Bibasilar atelectasis
with no
definite focal consolidation. Consider advancing endotracheal
tube 4 cm for optimal placement.
Brief Hospital Course:
65 yo F presents with tremors, weakness, falls and hypoxic
respiratory failure.
Hypercarbic and Hypoxic Respiratory Failure: Likely secondary to
hypoventilation from opioids/benzodizapenes with possible
contribution from asthma/COPD exacerberation plus H. influenzae
CAP. Also concern for ingestion given difficult social situation
at home (husband with multiple myeloma, verbally abusive per PCP
[**Name Initial (PRE) 12883**]), h/o depression and positive amphetamines, although
patient adamantly denies any inappropriate ingestions. She was
extubated [**4-12**], three days into admission, without difficulty.
Received vanc/zosyn in ED initially, however transitioned to
ceftriaxone and azithromycin and completed a seven day course.
She was placed on a fast steroid taper for possible asthma
exacerbation. She was noted to be volume overloaded secondary to
extensive fluids given during initial presentation. She was
diuresed and ultimately was able to oxgyenate on room air.
Ambulatory saturation prior to d/c was 92-93% RA.
Tremor: Noted after re-starting high dose Paxil at 40 mg daily.
Seen with activity and rest which is atypical in nature. This is
possibly secondar to high Paxil dose as this is a known to cause
tremor. She was also noted to have a high TSH and as such, her
synthroid dose was increased though this is not very likely to
be the cause of her tremor. Her tremor resolved prior to
discharge. If it recurs, recommend consideration for a
neurology consultation. She was discharged on 20 mg of paxil
daily.
Elevated LFTs: Unclear etiology, however normalized after acute
illness resolved.
Altered Mental Status: UTox screen positive for amphetamines and
opiates plus her home meds. Interestingly, patient denies taking
any illicit substances. Also, home meds plus acute renal failure
may have worsened mental status. Also, CAP may have contributed.
Mental status appropriate for latter part of hospitalization.
Decreased Paxil to 20 mg daily and Trazadone 50 mg [**Hospital1 **].
Acute Renal Failure: On admission: 1.5 with uncertain baseline.
Improved to 1.1. Possibly secondary to pre-renal etiology in
setting of acute illnes and improvement with IVFs.
Depression: Patient admits to having a lot of stress at home as
her husband is in treatment for MM. Decreased paxil and
trazadone as above. Stronly advised f/u with psychiatrist in the
outpatient. Patient states she has a psychiatrist referral from
her PCP, [**Name10 (NameIs) **] has not called to make this appointment. She
declined any assistance with this.
Chronic Pain: Initially held home methadone, however restarted
this to full home dose of 10 TID.
Asthma: Completed prednisone taper as above plus
advair/singulair and albuterol prn.
Elevated troponin: Initially Trop T elevated to 0.09 with flat
CKs in setting of ARF. Patient ruled out for MI.
Incontinence: Patient states this is a new complaint. Patient
should follow up with urology in the outpatient.
Medications on Admission:
Paxil 40mg PO daily
Methadone 10mg PO qid
Trazodone 100mg PO tid
Levothyroxine 150mcg PO daily
Symbicort 160/4.5
Singulair 10mg IH
Albuterol MDI prn
Lorazepam 1mg PO tid prn anxiety
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): Hold for loose stools.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day): While patient is not ambulating.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*6 Tablet(s)* Refills:*0*
7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) IH Inhalation twice a day.
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for Anxiety.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-31**] IH Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] [**Hospital1 189**]
Discharge Diagnosis:
Primary:
Community Acquired Pneumonia
Asthma Exacerbation
Depression
Chronic Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the ICU for respiratory failure requiring
intubation. You were found to have pneumonia and were treated
with antibiotics. You were also given steroids in case your
asthma was contributing to your respiratory failure. You were
successfully removed from the breathing machine [**4-12**]. You
continued to require supplemental oxygen as you still had extra
fluid in your lungs. We gave you lasix to help with this. You
will continue to be monitored closely in the rehab for further
removal of fluid.
You also had significant tremors and anxiety during your
hospitalization. When your medication doses were lowered, your
tremors resolved. It is important that you follow up with your
primary care doctor and your psychiatrist to help manage your
medications.
You should continue all of your medications with the following
important changes:
1. Increase Levothyroxine to 175 mcg daily as your thyroid tests
were suggestive that your current dose was not high enough
2. Decrease Paxil to 20 mg daily
3. Decrease Trazadone to 50 mg twice per day
It is important that you keep your doctor's appointments.
Followup Instructions:
You should follow up with your primary care doctor once you
leave the rehab. Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 6955**] at ([**Telephone/Fax (1) 27848**].
|
[
"276.69",
"724.5",
"788.30",
"584.9",
"338.29",
"244.9",
"333.1",
"780.09",
"E939.0",
"493.92",
"790.5",
"518.81",
"482.2",
"458.8",
"304.00",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8689, 8752
|
4308, 5937
|
305, 350
|
8878, 8878
|
2783, 2783
|
10206, 10398
|
2071, 2152
|
7504, 8666
|
8773, 8857
|
7297, 7481
|
9061, 10183
|
3720, 4285
|
2167, 2764
|
246, 267
|
378, 1804
|
2800, 3703
|
6356, 7271
|
8893, 9037
|
1826, 1974
|
1990, 2055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,724
| 110,301
|
34603
|
Discharge summary
|
report
|
Admission Date: [**2149-4-8**] Discharge Date: [**2149-5-15**]
Date of Birth: [**2074-9-22**] Sex: M
Service: NEUROLOGY
Allergies:
Codeine / NSAIDS / lamotrigine
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
[**2149-4-25**] Dr. [**Last Name (STitle) **]
[**Name (STitle) 2325**] craniotomy for open brain biopsy
History of Present Illness:
The pt is a 74 yoM with a history of complex partial seizure and
sometimes secondary generalization.
Presented with [**2149-4-5**] by his wife with mental status change, at
11am was confused with slurred speech, there noted to be
hypertensive 210/106 (patient not taking medications as
prescribed), NCHCT was normal and then admitted for management
of
seizures and HTN.
Zonegran was decreased to 100mg daily, continue keppra and
started Topamax 25mg daily, EEG showed PLEDs every 1- 1.5
seconds
followed by generalized slowing, --> thought to be in partial
complex status, Keppra 500mg and loaded with Dilantin 250mg IV
and 200mg PO. Topamax was further increased to 50mg [**Hospital1 **]. [**Hospital1 18**]
was called and patient transferred for further management.
Past Medical History:
SEIZURE Hx:
Multiple complex partial seizures sometimes with secondary
generalization: 1st Sz [**10/2144**],
Semiology: garbled speech, disorientation,
currently on: Keppra, Zonegran,
AEDs in past:
Lamictal --> d/c [**12-19**] tremors
T8-T9 extramedullary intradural thoracic meningioma sp resection
in [**2143**] c/b seroma at the site of his surgical incision found to
be growing MRSA.
DVT in [**2144-10-17**]; ? PE (no documentation)
? PRES : [**2144-10-17**] (MRI of the brain that showed increased
T2 hyperintensities in the bilateral occipital and posterior
right parietal lobe consistent with posterior reversible
encephalopathy syndrome)
Vertebral artery stenoses (b/l)
Tremor (thought to be medication related and not parkinsonian,
large amplitude)
Neuropathy: burning in toes bilaterally
HTN - Amitriptyline
HL - Lipitor,
PVD - left leg bypass done by Dr. [**First Name (STitle) 10378**] in [**Hospital1 1474**] for 65%
stenosis of a right leg artery.
Hx of asystole 30secs, requiring chest compressions
Social History:
He finished high school. He was a former butcher. He is
retired. He is married to [**Doctor Last Name 2048**]. Does not smoke cigarettes,
drink alcohol, or use any illegal drugs. He did skip the first
grade. He had no learning disabilities.
Family History:
His maternal uncle had 2 children and both of these cousins had
epilepsy. The patient himself has no history of birth
complications, or head trauma.
Physical Exam:
At admission:
Vitals: T: Afebrile P: 76 R: 16 BP: 142/72 SaO2: 96%RA
General: Alert, comfortable, confused and perseverative
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.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person only. NOT able to
relate history given perseveration and confusion. Attentive but
not able to follow commands "stick out your tongue, show me your
teeth". Language is fluent with impaired repetition and
impaired
comprehension. Pt. was NOT able to name both high and low
frequency objects. Speech was not dysarthric. NOT Able to
follow
both midline and appendicular commands. Memory was not assessed.
Apraxia / neglect could not be assessed.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
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. Low frequency tremor in
the
right finger/hand, also demonstrated intermittent larger
amplitude low frequency rhythmic jerking in his RLE. Pronator
drift could not be assessed.
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 5 5 5 5 5 5 5 5 5
R 4- 4+ 4 NA NA NA 5 5 5 5 5 5 5
-Sensory: No deficits to light touch or noxious stimuli. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R could not be assessed given the ongoing rhythmic activity
Plantar response was extensor on the right and flexor on the
left.
-Coordination: defered
-Gait: defered
Pertinent Results:
[**2149-4-8**] 05:39PM BLOOD WBC-7.9 RBC-4.81 Hgb-14.9 Hct-45.3 MCV-94
MCH-30.9 MCHC-32.8 RDW-13.0 Plt Ct-156
[**2149-4-8**] 05:39PM BLOOD PT-28.7* PTT-37.7* INR(PT)-2.8*
[**2149-4-8**] 05:39PM BLOOD Glucose-121* UreaN-25* Creat-1.5* Na-141
K-4.3 Cl-106 HCO3-25 AnGap-14
[**2149-4-10**] 05:51AM BLOOD Glucose-154* UreaN-19 Creat-1.3* Na-137
K-6.0* Cl-104 HCO3-22 AnGap-17
[**2149-4-20**] 05:20AM BLOOD Glucose-141* UreaN-13 Creat-1.3* Na-143
K-3.7 Cl-105 HCO3-28 AnGap-14
[**2149-4-8**] 05:39PM BLOOD ALT-27 AST-20 LD(LDH)-168 AlkPhos-73
TotBili-0.8
[**2149-4-8**] 05:39PM BLOOD Calcium-10.5* Phos-2.3* Mg-2.0
[**2149-4-9**] 07:30PM BLOOD Albumin-4.1
[**2149-4-15**] 08:38AM BLOOD calTIBC-160* TRF-123*
[**2149-4-8**] 05:39PM BLOOD Phenyto-7.7*
[**2149-4-16**] 03:44PM BLOOD Lactate-1.7
[**2149-4-15**] 08:38AM BLOOD PREALBUMIN-Test
[**2149-4-18**] 04:58AM BLOOD VGKC ANTIBODY -PND
[**2149-4-18**] 04:58AM BLOOD GLUTAMIC ACID DECARBOXYLASE-PND
[**2149-4-8**] 05:38PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2149-4-8**] 05:38PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2149-4-8**] 05:38PM URINE RBC-50* WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
[**2149-4-13**] 01:37PM URINE Hours-RANDOM Creat-52 Na-63 K-10 Cl-58
[**2149-4-13**] 12:30PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-4* Polys-0
Lymphs-67 Monos-26 Macroph-7
[**2149-4-13**] 12:30PM CEREBROSPINAL FLUID (CSF) TotProt-69*
Glucose-121
[**2149-4-17**] 12:30PM CEREBROSPINAL FLUID (CSF) 14-3-3-PND
[**2149-4-13**] 12:30PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
[**2149-4-13**] 11:37 am CSF;SPINAL FLUID Source: LP TUBE #3.
GRAM STAIN (Final [**2149-4-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
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 [**2149-4-16**]): NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
[**2149-4-11**] 3:13 pm URINE Source: Catheter.
**FINAL REPORT [**2149-4-13**]**
URINE CULTURE (Final [**2149-4-13**]):
CITROBACTER KOSERI. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 79405**],
[**2149-4-11**].
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
347-5871C,
[**2149-4-11**].
[**2149-4-11**] 11:39 am URINE Source: Catheter.
**FINAL REPORT [**2149-4-14**]**
URINE CULTURE (Final [**2149-4-14**]):
CITROBACTER KOSERI. >100,000 ORGANISMS/ML..
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.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER KOSERI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S <=16 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
[**2149-4-8**] 5:38 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2149-4-10**]**
MRSA SCREEN (Final [**2149-4-10**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
EEG:
[**2149-4-8**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of the diffuse encephalopathic features with focal and
multifocal
features. There is diffuse background slowing but also
asymmetric
slowing in the left parieto-occipital region and independently
in the
right parietal area. Superimposed upon the leftsided slow wave
activity
is an exceptionally active paroxysmal epileptiform transient
with a
frequency of 0.5-1 Hz. This appears to have both an electrical
field
effect in the right occipital pole as well as synaptic
transmission to
the right parietal-occipital region. There were several events
that
appear to be clonic seizures of the right leg but no clear
electrographic correlate.
[**2149-4-9**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of diffuse encephalopathic slowing seen as a widely distributed
abnormality but superimposed structural features in the left
posterior
quadrant and independently in the right central parietal
regions. There
is extremely active paroxysmal interictal discharge in the
posterior
quadrant on the left maximum at the O1 electrode. No sustained
electrographic seizures or clinical events were reported or
recorded.
[**2149-4-10**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of the persistent diffuse encephalopathy with superimposed more
significant left hemisphere abnormality suggesting structural
pathology
in the more posterior aspects of the left hemisphere and
possible
independent structural pathology in the right parietal central
region.
Superimposed upon this is a very active interictal epileptic
discharge
in the left occipital pole. No sustained seizures were
identified.
[**2149-4-11**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of diffuse encephalopathic changes and multifocal independent
structural
pathologic left greater than right. There continues to be an
extremely
active paroxysmal interictal epileptic discharge in the left
occipital
pole.
[**2149-4-12**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of both diffuse encephalopathic features as well as multifocal
slow wave
abnormalites suggesting multifocal structural pathology. The
left
hemisphere appears more involved than the right. There continues
to be
paroxysmal interictal epileptiform activity in the left
occipital pole.
[**2149-4-13**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of a diffuse encephalopathy with multifocal superimposed slow
wave
features. This activity is over the left occipital parietal and
the
right central parietal regions. There continues to be an active
interictal epileptiform transient in the left occipital pole.
MR head with and without contrast:
IMPRESSION:
Restricted diffusion constrained to the left parietal and
temporal cortical
grey matter. The differential diagnosis for this pattern is
broad and it is
most commonly caused by vascular ischemia, however, in a patient
with complex
partial seizures originating from this location, post-ictal
changes may
present similarly. The findings of left cerebral atrophy and
possible crossed
cerebellar diaschisis is suggestive of [**Doctor Last Name 73**] syndrome. This
can be
further explored using MRI spectroscopy, perfusion, and
tractography. Viral
etiology must also be considered. The clinical significance of
the relatively
new microhemorrhages at these loci is unclear.
Carotid US:
IMPRESSION: Although there is plaque involving the proximal
internal carotid
arteries bilaterally, no hemodynamically significant stenosis
noted. Flow in
the vertebral arteries is prograde.
TTE:
Conclusions
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. There is no ventricular septal defect. 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. Physiologic mitral regurgitation is seen (within
normal limits). 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 due to body habitus. No
cardiac source of embolus seen. Left ventricular systolic
function is probably normal, a focal wall motion abnormality
cannot be excluded. The right ventricle is not well seen. No
significant valvular abnormality. Unable to assess pulmonary
artery systolic pressure.
Paraneoplastic Autoantibody Eval, S
Interpretive Comments
No informative autoantibodies were detected in this
evaluation. However,
a negative result does not exclude neurological autoimmunity
with or
without associated neoplasia.
Anti-Neuronal Nuclear Ab, Type 1
[**Location (un) **]-1, S Negative titer
<1:240
Anti-Neuronal Nuclear Ab, Type 2
[**Location (un) **]-2, S Negative titer
<1:240
Anti-Neuronal Nuclear Ab, Type 3
[**Location (un) **]-3, S Negative titer
<1:240
Anti-Glial Nuclear Ab, Type 1
AGNA-1, S Negative titer
<1:240
Purkinge Cell Cytoplasmic Ab Type 1
PCA-1, S Negative titer
<1:240
Purkinge Cell Cytoplasmic Ab Type 2
PCA-2, S Negative titer
<1:240
Purkinge Cell Cytoplasmic Ab Type Tr
PCA-Tr, S Negative titer
<1:240
Amphiphysin Ab, S Negative titer
<1:240
CRMP-5-IgG, S Negative titer
--Reference Value--
Negative at <1:240
Titers lower than 1:240 may be detectable by recombinant
CRMP-5 western
blot analysis. CRMP-5 western blot analysis will be done by
request on
stored serum (held 4 weeks). This supplemental testing is
recommended in
cases of chorea, vision loss, cranial neuropathy and
myelopathy. Contact
[**Name (NI) **] Laboratory Inquiry at 1-[**Telephone/Fax (1) 79406**] (internally [**4-/5837**])
to add-on
CRMP-5-IgG Western Blot, Serum.
Striational (Striated Muscle) Ab, S Negative titer
<1:60
P/Q-Type Calcium Channel Ab 0.00 nmol/L
<=0.02
N-Type Calcium Channel Ab 0.00 nmol/L
<=0.03
ACh Receptor (Muscle) Binding Ab 0.00 nmol/L
<=0.02
AChR Ganglionic Neuronal Ab, S 0.00 nmol/L
<=0.02
Neuronal (V-G) K+ Channel Ab, S 0.00 nmol/L
<=0.02
Test Performed at:
[**Hospital **] Medical Laboratories, [**Street Address(2) 56325**] SW, [**Location (un) 15739**],
[**Numeric Identifier 79407**]
Complete report on file in the laboratory.
Comment: [**Hospital3 **] PARANEOPLASTIC PANEL ANTI NMDA AB
Anti-NMDA negative
14-3-3 negative
Anti-GAD negative
HIV Ab negative
HCV ab negative
Brief Hospital Course:
74yoM h/o complex partial seizures, DVT and PVD on warfarin,
PRES, bilateral vertebral artery stenoses, thoracic meningioma,
and HTN p/w suspected complex partial status epilepticus with
right arm and leg myoclonus.
.
[] Seizures/Encephalopathy - The patient presented initially to
an OSH with confusion, hypertension, and right arm and leg
myoclonus superimposed on his baseline right thumb/finger
flexion tremor. His medications were altered with the cessation
of ZNS, initiation of TPX, and increased doses of LEV. His
seizures did not abate, and so TPX and LEV were increased and
PHT was added. When this did not control his seizures, he was
transferred to [**Hospital1 18**] for further care. He was initially noted to
be very inattentive, perseverative, and unable to follow complex
commands (with perseveration of motor tasks). He also had a
fluent aphasia. He had an extensive investigation including
laboratory data, infectious workup (which did not reveal any
signs of infection, including of the CSF) with empiric treatment
for meningitis and encephalitis, and reimaging of the brain
which revealed interval atrophy of the left cerebral hemisphere.
This raised the question of possible atypical [**Doctor Last Name **]
encephalitis versus another in inflammatory encephalitis that
might cause seizures. He was monitored on cvEEG which only
showed one clear clinical seizure with several subclinical
seizures while asleep. He was continued on LEV, PHT (with levels
monitored) and standing LZP. A brain biopsy was performed by
Neurosurgery on [**2149-4-25**] which only showed reactive changes
without clear specificity in diagnosis. Given the concern for
inflammatory encephalitis, he was given an empiric treatment of
5 days of IV methylprednisolone (1 gram) which correlated with
some improvement in his seizures and clinical exam, though this
also occurred simultaneously with an increase in his LZP from
0.25 [**Hospital1 **] to 0.5 TID. Due to concerns for oversedation, his LZP
was changed to Clonazepam 0.5 [**Hospital1 **]. With limited improvement
observed with IV corticosteroids, he also underwent 5 days of
IVIG for treatment of presumed auto-immune or paraneoplastic
inflammatory encephalitis. His clinical condition has gradually
improved with hopes that his clinical condition will continue to
improve as the effect of corticosteroids and IVIG may be delayed
by days to weeks.
.
[] Chronic DVT - He was maintained on a continuous infusion of
Heparin for chronic DVT and was transitioned back to warfarin.
.
[] HTN - His lisinopril had to be stopped due to [**Last Name (un) **] in the
setting of concurrent acyclovir therapy. He was switched to
amlodipine alongside his metoprolol tartrate.
.
[] UTI - On [**4-11**] his UCx grew Citrobacter and Enterococcus which
was treated with CTX 1 gm q24h x 7 days.
.
PENDING STUDIES:
[ ] Anti-NMDA serum antibody
[ ] Anti-[**Last Name (un) **] serum antibody
[ ] HHV6 CSF antibody
.
TRANSITIONAL CARE ISSUES:
[ ] Neurology - Please monitor his seizure frequency. Please
consider additional testing for etiologic investigation of his
progressive epilepsy. Please adjust his Phenytoin,
Levetiracetam, and Clonazepam doses.
[ ] Neurology - Consider outpatient plasmapheresis or additional
IVIG treatments if his condition is still thought to be
secondary to autoantibody-mediated inflammatory encephalitis.
[ ] Anticoagulation - Please maintain his INR between [**12-20**] with
adjustments to his warfarin dose.
[ ] Wound Care - Please continue Silvadene/xeroform [**Hospital1 **] dressing
changes to his left arm ulcer.
.
Wound care:
Site: left forearm
Type: Traumatic Ulcer / Skin Tear
Change dressing: [**Hospital1 **]
Comment: Silvadene and Xeroform per Plastic Surgery
Medications on Admission:
Amitriptyline 10mg qhs
Atorvastatin 80mg qhs
Colchicine
eszopiclone (lunesta) 3mg tab qhs
Keppra 1500 [**Hospital1 **]
Lisinopril 20mg [**Hospital1 **]
Lorazepam 0.5 daily prn anxiety
Metoprolol tartrate 50mg [**Hospital1 **]
Omeprazole 20mg EC daily
Vitamin D3
warfarin 5mg daily
Zonegran 100mg [**Hospital1 **]
OTC:
B12
Flaxeed
folic acid 0.4 qam
Vit E 400 unit
Turmeric root
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
hold for SBP < 110
3. Atorvastatin 80 mg PO DAILY
4. Phenytoin Infatab 150 mg PO Q8AM AND Q4PM
5. Phenytoin Infatab 200 mg PO HS
6. Senna 1 TAB PO BID constipation
hold for loose stools
7. Docusate Sodium 100 mg PO BID
8. Clonazepam 0.5 mg PO BID
9. LeVETiracetam 1500 mg PO BID
10. Metoprolol Tartrate 50 mg PO BID
hold for SBP<100 and HR<55
11. Silver Sulfadiazine 1% Cream 1 Appl TP [**Hospital1 **] left arm ulcer
12. Warfarin 5 mg PO DAILY16
13. Famotidine 20 mg PO Q12H
14. Vitamin D 400 UNIT PO DAILY
15. Colchicine 0.6 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Seizure, Encephalopathy/Inflammatory
Encephalitis
SECONDARY DIAGNOSIS: Hypertension, Chronic Deep Venous
Thrombosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 79408**],
You were hospitalized due to symptoms of RIGHT ARM AND LEG
SHAKING and CONFUSION resulting from SEIZURES. The brain is the
part of your body that controls and directs all the other parts
of your body. It normally communicates with electrical signals.
When an abnormal electrical signal develops and forms a short
circuit, this produces a seizure. Seizures produce many
different symptoms and can occur again. In particular, seizures
that cause loss of consciousness (even if only temporary) can
endanger you and place you at risk of harm. Accordingly, we
would like to help you prevent the recurrence of seizures.
We are changing your medications as follows:
1. Please take PHENYTOIN 150 mg in the morning, 150 mg in the
afternoon, and 200 mg at night.
2. Please take LEVETIRACETAM 1500 mg in the morning and 1500 mg
at night.
3. Please take CLONAZEPAM 0.5 mg in the morning and 0.5 mg at
night.
4. Please take WARFARIN 5 mg each day (with goal INR [**12-20**]). This
should be checked by the rehab facility and your primary care
physician.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek medical
attention.
Because of the risk of future seizures, you must take the
following SEIZURE PRECAUTIONS:
- You cannot drive a motor vehicle for at least 6 months after
your last seizure during which you had impairment of
consciousness (a staring spell or full loss of consciousness).
- Avoid swimming in a pool or body of water unattended.
- When using the bathroom at home, please do not lock the door
(so that if you have a seizure someone can reach you).
- Do not climb to high heights (e.g. trees, ladders, etc.).
- Do not engage in activities where temporary impairment of
consciousness might cause you to fall or be placed in a
dangerous position.
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
NEUROLOGY Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2149-5-19**] 1:00pm, [**Hospital1 69**],
[**Location (un) 830**], [**Location (un) 86**], MA
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22,709
| 123,898
|
20000
|
Discharge summary
|
report
|
Admission Date: [**2192-11-12**] Discharge Date: [**2192-12-14**]
Date of Birth: [**2155-7-2**] Sex: F
Service: Transplant Surgery Service
HISTORY OF PRESENT ILLNESS: Briefly, the patient is a
73-year-old female who was transferred from an outside
hospital with fulminate acute hepatitis A infection who had
worsening liver function. She had been on a recent trip to
[**State 108**] and developed nausea, vomiting, and weight loss.
She was seen by her primary care physician and was noted to
have increasing liver function tests and was admitted for
this. She slowly worsened over time and was transferred to
the Intensive Care Unit here at [**Hospital1 188**].
PAST MEDICAL HISTORY: Past medical history is significant
for bronchiectasis.
PAST SURGICAL HISTORY: No past surgical history.
MEDICATIONS ON ADMISSION: She took no medications at home.
MEDICATIONS ON TRANSFER: She was on lactulose and
Neutra-Phos upon transfer.
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient was afebrile, her heart rate was 64, her
blood pressure was 108/60, her respiratory rate was 20, and
her oxygen saturation was 99% on room air. In general, she
was in no apparent distress. She was jaundiced and
diaphoretic. Cardiovascular examination revealed her heart
was regular in rate and rhythm. There were no murmurs, rubs,
or gallops. The lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended. She had notable ascites. She was alert,
awake, and oriented. She had positive asterixis. She had no
edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed her white blood cell count was 14.4, her
hematocrit was 41.4, and her platelet count was 325.
Chemistries revealed the patient's sodium was 136, potassium
was 5.6, chloride was 100, bicarbonate was 22, blood urea
nitrogen was 3, creatinine was 0.7, and her blood glucose was
107. Her calcium was 9.6, her magnesium was 1.9, and her
phosphorous was 3.7. Her alanine-aminotransferase was 1600,
her aspartate aminotransferase was 1060, her alkaline
phosphatase was 129, her total bilirubin was 33.5, and her
albumin was 3.6. Her hepatitis panels were negative except
for hepatitis A. Her human immunodeficiency virus was
negative as well. She had an INR of approximately 4.2.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Surgical Intensive Care Unit for close monitoring and
was continued on the lactulose.
She slowly deteriorated throughout her hospital course, and
her laboratories continued to elevate. Her
alanine-aminotransferase and aspartate aminotransferase
slowly improved; however, her synthetic function and INR
continued to elevate.
On [**2192-11-20**] the patient underwent an orthotopic
liver transplantation for her fulminate hepatitis A. Please
see the Operative Report for further details. The patient
was transferred to the Intensive Care Unit postoperatively.
She was continued on plasmapheresis due to the fact that she
had a donor mismatched liver, and the patient continued to be
monitored for this. She underwent daily plasmapheresis for
14 days. Afterwards, the patient continued to do well.
Her liver function tests and synthetic function slowly
improved after transplantation; however, she continued to
have very high fevers. Multiple cultures were done. Her
lines were changed, and her fever slowly defervesced. She
was given a full course of Zosyn, vancomycin, and Flagyl.
She also requested Unasyn perioperatively as well as a course
of meropenem throughout her hospital course.
The Hematology Service was consulted for her phoresis, and a
Quinton catheter was placed in her right groin. After her
multiple fevers the catheter was moved to her left groin.
After completion of her phoresis (14 days), the Quinton
catheter was removed. The patient's fever slowly defervesced
slowly after that time. She was slowly weaned from the
ventilator and was able to be successfully extubated.
On postoperative day six, she was noted to have increasing
liver function tests. An ultrasound was done which showed a
thrombus in her portal vein. Therefore, she was returned to
the operating room for a portal vein thrombectomy. Again,
she was in the midst of her phoresis time, and it was decided
that her phoresis would be changed from induction with fresh
frozen plasma to induction with 50% albumin and 50% fresh
frozen plasma. During her original operation, a splenectomy
was performed. After multiple fevers a computed tomography
scan revealed fluid in the left upper quadrant. A pigtail
catheter was placed, and it was found that she had a amylase
from this pigtail of 63,000. Therefore, there had a
pancreatic leak. The pigtail catheter was kept in place
throughout her hospital stay.
The patient continued to do well and again was hoped to be
weaned from the ventilator. On postoperative days 11 and 5,
she was extubated. She had multiple episodes of distention.
A computed tomography scan showed just large bowel
distention. Multiple cultures were Clostridium difficile
were negative. The patient's distention resolved after a
dose of neostigmine and tube decompression. She was
continued on total parenteral nutrition for nutritional
support during her long Intensive Care Unit stay.
The patient was ultimately stabilized from her
transplantation, and her phoresis was completed. Her fevers
resolved. The titers of hepatitis A slowly decreased during
post phoresis, and her last titer was 16 prior to discharge.
The patient was transferred out to the floor. The Physical
Therapy Service was consulted for ambulation. Her mental
status slowly improved throughout her hospital stay, and she
was deemed safe to go home by Physical Therapy.
A repeat computed tomography angiogram was performed after
the patient returned to the floor which was negative. A
liver biopsy was also performed which showed no rejection.
It was decided at this time that the patient was stable. She
was kept on her immunosuppressives which included prednisone,
cyclosporine, and mycophenolate mofetil with adequate levels.
She was monitored closely for levels throughout her hospital
stay, and her cyclosporine was adjusted daily. She was
stabilized on approximately 125 mg of cyclosporine at the
time of discharge.
DISCHARGE DISPOSITION: The patient was to be discharged on
[**2192-12-14**] to home. A pigtail catheter was in place.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Cyclosporine 125 mg by mouth twice per day.
2. Albuterol nebulizers as needed.
3. Percocet one to two tablets by mouth q.4h. as needed.
4. Lasix was given intermittently for diuresis; however, it
was stopped prior to discharge.
5. Mycophenolate mofetil 1000 mg by mouth twice per day.
6. Prevacid 30 mg by mouth once per day.
7. Prednisone 20 mg by mouth once per day.
8. Valcyte 900 mg by mouth once per day.
9. Lamivudine 100 mg by mouth once per day.
10. Bactrim single strength tablets one tablet by mouth once
per day.
11. Fluconazole 400 mg by mouth once per day.
12. Colace 100 mg by mouth twice per day (as a stool
softener).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with the
Transplant Center at the arranged times to have serial blood
draws and monitoring of her liver function as well as her
cyclosporine level.
2. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] as well as with the Liver Service at the Transplant
Center.
DISCHARGE STATUS: The patient was to be discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. Fulminate hepatitis A.
2. Status post orthotopic liver transplantation.
3. Pancreatic leak; status post pigtail catheter placement.
4. Bronchiectasis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 48821**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2192-12-13**] 20:47
T: [**2192-12-13**] 21:00
JOB#: [**Job Number 53894**]
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[
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6436, 6533
|
7801, 8243
|
6560, 7252
|
847, 881
|
7285, 7729
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793, 820
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189, 688
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907, 2418
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711, 768
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,169
| 135,468
|
2776
|
Discharge summary
|
report
|
Admission Date: [**2201-2-9**] Discharge Date: [**2201-2-26**]
Date of Birth: [**2119-4-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Guaifenesin AC
Attending:[**Doctor First Name 2080**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Thoracentesis with placement and removal of pleurex catheter
Bronchoscopy with biopsy
History of Present Illness:
81F w/ history of depression in the past, hypertension,
hypercholesterolemia, and hypothyroidism, was in usual state of
health until about 2 weeks ago when she called her PCP c/o SOB
and some confusion. PCP was able to set up chest x-ray, CT scan
of the chest, MRI of the brain. Chest CT showing a near complete
collapse of the left upper lobe of the lung, with mediastinal
and hilar lymphadenopathy, and an MRI of the brain with multiple
lesions consistent with likely metastasis.
Was going to have outpatient evaluation however had worsening
SOB and referred to ED. On arrival was triggered for
hypoxia/hypotension upon arrival. +coughing. SOB worse with
exertion. No fever. No abd pain. No CP. CT on [**2-2**] showed Left
upper lobe collapse, concerning for bronchogenic carcinoma.
possible mets seen.
In the ED, initial VS were were significant for O2 sats of 80%
on room air. CXR shwoed left sided pleural effusion. She was
seen by IP who placed pig-tail catheter and removed 1L fluid.
Her hypoxia improved and prior to transfer she was requiring 1L
NC. She became hypotensive to SBP 80 and received 1L NS with SBP
coming up to low 90's. Second liter running at time of sign out.
Labs signficiant for WBC of 16, Cr of 1.9 (baseline 1.0), K of
2.6. She received 40meQ KcL and K in her IVF. She was also
started on ceftriaxone and levofloxacin for possible PNA.
Levofloxacin caused red splotches
On arrival to the MICU, She is complaining of left shoulder pain
with coughing and deep breaths.
Past Medical History:
- Depression
- high cholesterol
- hypertension
- hypothyroidism
- osteoarthritis
- ulcerative proctitis
Social History:
60 pack year smoking history. Quit 15-20 years ago.
She is widowed. She lives alone in [**Location (un) 745**].
She has two daughters who are very involved. She worked
previously as a bookkeeper. She is quite active. She spends
time with her friends, she does some volunteer work, and she is
an avid and apparently very good bridge player.
Family History:
Non-contributory to this presentation.
Physical Exam:
On Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Presentation:
WBC-16.1* RBC-3.89* Hgb-10.0* Hct-31.3* MCV-80* RDW-15.8* Plt
Ct-733*
--Neuts-92.6* Lymphs-3.8* Monos-2.5 Eos-0.9 Baso-0.2
PT-17.1* PTT-36.8* INR(PT)-1.6*
Glucose-154* UreaN-42* Creat-1.9* Na-140 K-2.6* Cl-97 HCO3-27
Calcium-8.4 Phos-2.8 Mg-1.7
On Discharge:
Other Key Lab Results:
Pleural Fluid Analysis [**2201-2-9**]:
WBC-4800* RBC-900* Polys-77* Lymphs-13* Monos-0 Meso-1* Macro-4*
Other-5*
TotProt-3.4 Glucose-145 LD(LDH)-167 Cholest-67 Triglyc-16
Pleural Fluid Cytology:
ATYPICAL.
Few atypical cells (see note).
Note: Rare groups of atypical epithelioid cells are seen in
a background of reactive mesothelial cells, histiocytes, and
mixed inflammatory cells. Two concurrent hematology slides
(1364D) were also reviewed. A cell block specimen
(S12-4617D) was prepared in an attempt to better
characterize the atypical cells, but these cells were not
seen on the cell block preparation. Preliminary results were
e-mailed to Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 13670**] on [**2201-2-10**], and the final
results were communicated to Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2201-2-12**].
==============
MICROBIOLOGY
==============
All blood, urine, and pleural fluid cultures without growth.
==============
OTHER STUDIES
==============
ECG [**2201-2-9**]:
Baseline artifact. Sinus rhythm. Low voltage. Borderline
intraventricular
conduction delay. ST-T wave abnormalities. Since the previous
tracing
of [**2187-12-21**] voltage has decreased. ST-T wave abnormalities are
new. Clinical correlation is suggested.
Chest Radiograph [**2201-2-9**]
IMPRESSION:
1. Left hilar mass with left upper lobe collapse and likely
partial left
lower lobe collapse. Small left pleural effusion also noted.
2. Increasing airspace consolidation in the right upper lobe
abutting the
minor fissure is compatible with pneumonia.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2201-2-20**]
6:04 PM
A clip is identified within the lower pole of the left thyroid
gland, unchanged from prior. The remainder of the gland is
homogeneous without focal nodule. No supraclavicular or axillary
lymphadenopathy is identified. Multiple enlarged mediastinal
lymph nodes overall appear slightly larger as compared to recent
prior. A pretracheal lymph node previously measured 11 mm in
short-axis diameter and is unchanged (3:40) and a subcarinal
lymph node currently measures 22 mm and previously measured 19
mm (3:55). A right hilar lymph node measures 17 mm and
previously measured 15 mm (3:53). A superior pretracheal lymph
node is
enlarged measuring 15 x 11 mm as compared to 12 x 7 mm on the
prior (3:29).
The heart size is normal, and there is no pericardial effusion.
Extensive
coronary atherosclerotic vascular calcifications are unchanged.
The thoracic aorta is non-aneurysmal throughout its course and
demonstrates no signs of acute aortic syndrome. There is no
pulmonary embolism to subsegmental levels.
There is unchanged complete collapse of the left upper lobe.
However, there is now complete lobar collapse of the left lower
lobe; these findings are new from prior CT though similar to
multiple recent chest radiographs. The left mainstem bronchus is
obliterated just beyond its origin, which may be due to mucous
plugging or bronchial invasion by tumor. There is increasing
midline shift of mediastinal structures, consistent with volume
loss and progressive atelectasis. There is increasing
non-hemorrhagic pleural fluid bilaterally, large on the left and
small on the right.
The aerated right lung demonstrates moderate-to-severe
centrilobular
emphysema. A calcified granuloma in the right lower lobe is
stable as
compared to prior examination (3J:71). An adjacent previously
described 3-mm nodule is not well seen. Interlobular septal
thickening, ground-glass
opacities, and micronodular opacities predominantly with a
perifissural
distribution have increased and now involve both the anterior
and posterior aspects of the right upper lobe, and perifissural
portions of the right middle and lower lobes. Regions of more
confluent consolidation along the inferior margin of the right
upper lobe along the major and minor fissure, may reflect
confluent nodularity or subsegmental atelectasis(500B:12). The
overall increase in reticular-nodular septal thickening and
ground-glass opacities suggest either progressive lymphangitic
spread of tumor, infection or asymmetric pulmonary edema.
Though not tailored for subdiaphragmatic evaluation, again seen
are multiple punctate hypodensities throughout the liver,
findings most consistent with biliary hamartomas. However, an
ill-defined hypodensity in segment [**Doctor First Name 690**]/VIII has increased in
size, now measuring 2.1 x 2.0 cm as compared with 1.1 x 1.3 cm
on the prior examination (3:98), findings concerning for
progression of disease. An additional 1.0 x 0.9 cm ill-defined
nodule is newly identified in segment VII and may be a new
metastatic lesion (3:99). The remainder of the upper abdominal
viscera appear within normal limits. Slight increase of the
enhancing soft tissue nodule in the posterior right anterior
wall.
OSSEOUS STRUCTURES: A healing fracture of the left 9th posterior
rib is
noted, possibly pathologic secondary to an underlying metastatic
lesion.
IMPRESSION:
1. Progressive atelectasis of the left lung, now with complete
lobar collapse of the left upper and lower lobes.
2. Increase in bilateral non-hemorrhagic pleural effusions,
large on the left and small on the right.
3. Occlusion of the distal aspect of the left mainstem bronchus,
which may be secondary to mucous plugging or invading tumor.
4. Overall slight increase in mediastinal adenopathy.
5. Progressive interlobular nodular septal thickening and
ground-glass
opacities in the right lung. Findings are nonspecific and may
reflect
asymmetric edema or infection, though the appearance is
concerning for
lymphangitic spread of tumor.
6. Increased size of a segment [**Doctor First Name 690**]/VIII liver lesion and a newly
identified segment VII lesion, findings concerning for worsening
metastatic disease.
7. Healing fracture of the left posterior 9th rib, likely
pathologic.
Portable TTE (Complete) Done [**2201-2-20**] at 4:12:51 PM FINAL
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is small.
Left ventricular systolic function is hyperdynamic (EF 75%). The
right ventricular cavity is dilated with depressed free wall
contractility. 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. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion. There is an anterior space
which most likely represents a prominent fat pad.
Compared with the findings of the prior study (images reviewed)
of [**2196-7-29**], findings now compatible with acute pulmonary
embolism
Brief Hospital Course:
81F with a PMH significant for depression, HTN, HLD,
hypothyroidism with significant pack-year smoking history who
presented with progressive dyspnea and hypotension with
increasing oxygen requirement in the context of recent diagnosis
of likely metastatic lung cancer.
# Bronchogenic carcinoma with brain metastases: Patient
presented with progressive dyspnea with CXR and CT imaging
([**2-2**]) confirming LUL collapse with no discrete mass identified,
but most concerning for bronchogenic carcinoma associated with
extensive hilar and mediastinal LAD. Numerous hepatic
hypodensities were also noted (although likely benign or cystic
- possible metastatic). MR imaging of the brain demonstrated
multiple small enhancing foci in bilateral cerebellar
hemispheres which likely represent metastases. Patient had no
neurological deficits but was started on dexamethasone at
presentation for brain metastases. Oncology and radiation
oncology were involved once malignancy confirmed. Given her poor
prognosis, she was moved to DNR/DNI and comfort care, with
inpatient hospice.
# Left sided post-obstructive pneumonia/effusion
Presented to the hospital with progressive dyspnea and found to
have a large left sided mass and pleural effusion. Initially
required MICU stay, then called out to floor. Returned to the
MICU with worsening of her hypoxia and dyspnea. She was treated
with vanc/zosyn for a pneumonia without any resolution.
Radiation was initially started, but with worsening clinical
status, this was no longer an option. Multiple family meetings
were held, with a transition to comfort care.
# HYPERTENSION - managed as an outpatient with HCTZ (thiazide)
with
# HYPERLIPIDEMIA - continue home dose Atorvastatin 10 mg PO
daily.
# HYPOTHYROIDISM - will continue on Levothyroxine 112 mcg PO
daily.
Patient expired on [**2201-2-26**]. She was with her family and
comfortable.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs by mouth every 4 hours as needed for shortness of breath
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth
daily
BENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth four times
a
day as needed for cough
CLONAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth at bedtime
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth daily
IBUPROFEN - (Dose adjustment - no new Rx) - 600 mg Tablet - 1
Tablet(s) by mouth twice a day as needed for headache
LEVOTHYROXINE - 112 mcg Tablet - 1 Tablet(s) by mouth daily
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth in AM
MIRTAZAPINE - (Prescribed by Other Provider) - 15 mg Tablet - 1
Tablet(s) by mouth at bedtime
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 puff by mouth in AM
Medications - OTC
ASPIRIN [ADULT LOW DOSE ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth daily
CALCIUM CARBONATE - 400 mg (1,000 mg) Tablet, Chewable - 2
Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
2,000 unit Capsule - 1 Capsule(s) by mouth daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
Bronchogenic carcinoma presumed metastatic with brain metastases
Malignant pleural effusion
Post obstructive pneumonia
Secondary Diagnoses:
Acute renal failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"197.7",
"162.8",
"584.9",
"244.9",
"519.19",
"569.49",
"486",
"272.0",
"305.1",
"427.32",
"799.02",
"V64.1",
"518.81",
"276.8",
"198.3",
"511.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91",
"38.91",
"92.29",
"34.04",
"96.04",
"96.71",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
13626, 13635
|
10349, 12237
|
321, 409
|
13859, 13868
|
3159, 3481
|
13924, 13934
|
2448, 2488
|
13594, 13603
|
13656, 13795
|
12263, 13571
|
13892, 13901
|
2503, 2503
|
13816, 13838
|
3496, 10326
|
270, 283
|
437, 1941
|
2517, 3140
|
1963, 2069
|
2085, 2432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,606
| 100,729
|
37399
|
Discharge summary
|
report
|
Admission Date: [**2158-1-18**] Discharge Date: [**2158-1-24**]
Date of Birth: [**2089-7-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted with R sided abdominal pain s/p diverting loop
colostomy.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 F presents to the ED today on POD 16 from a diverting
loop colostomy that was performed for an obstructing sigmoid
lesion. She was discharged on [**2158-1-9**] and was doing well. She
was in her usual state of health until 48 hrs ago when she
started feeling very weak, almost unable to walk up a flight of
stars. She also complains of right sided abdominal pain,
unrelated to po intake, that has worsened over the past 48 hrs
as
well. She denies any fevers, nausea, or vomiting. She does
report
chills, decreased urine output, as well as more liquid ostomy
output than usual. The output has now started thickening up
again.
Of not, Ms. [**Known lastname 84080**] had a colonoscopy on [**12-30**] that showed an
applecore lesion in the sigmoid colon at 30cm, and a stent was
placed. No biopsy taken.
Past Medical History:
polycystic kidney disease, HTN
Social History:
quit Tob 1y ago, formerly 1-2ppd x30y. + EtOH, 1-2 drinks
nightly. Lives at home with her eldest son.
Family History:
not applicable
Physical Exam:
PE: 97.6 80 87/59 --> (105/60 1L bolus) 16 100% RA
A&O x 3, NAD
PERRL, EOMI, anicteric sclera
Lips and tongue dry
Neck supple, no masses
RRR
CTAB
Abdomen soft, nondistended, gas and yellow stool in ostomy bag.
She is tender to palpation in the RUQ with guarding. Normal
bowel
sounds, negative [**Doctor Last Name 515**]. Midline incision well healed with old
steri-strips in place.
Ostomy digitalized without difficulty or pain. Guiac negative.
LE warm, no edema
Pertinent Results:
[**2158-1-18**] 11:50AM BLOOD WBC-11.8* RBC-3.80* Hgb-11.9* Hct-37.1
MCV-98 MCH-31.3 MCHC-32.0 RDW-13.6 Plt Ct-563*#
[**2158-1-18**] 11:50AM BLOOD Glucose-104* UreaN-34* Creat-2.1* Na-141
K-3.4 Cl-104 HCO3-22 AnGap-18
[**2158-1-20**] 02:45AM BLOOD Glucose-102* UreaN-22* Creat-1.6* Na-139
K-3.3 Cl-112* HCO3-19* AnGap-11
[**2158-1-23**] 06:58AM BLOOD Glucose-110* UreaN-10 Creat-1.1 Na-136
K-3.6 Cl-108 HCO3-21* AnGap-11
[**2158-1-23**] 06:58AM BLOOD Calcium-7.1* Phos-2.3* Mg-1.6
[**2158-1-18**] 11:56AM BLOOD Lactate-2.6* K-2.9*
Ct Scan [**2158-1-18**]
1. Mid lower abdomen small fluid collection with locule of gas
concerning for
abscess.
2. Diffuse bowel wall thickening of the large bowel, as well as
involvement
of several loops of small bowel, with mesenteric stranding.
Findings raise
concern for an infectious or inflammatory process.
3. Status post diverting colostomy and stent placement in the
rectosigmoid
colon with narrowing of the mid stent likely related to known
rectal mass.
4. Unchanged fusiform aneurysmal dilatation of the infrarenal
aorta up to 3.3
cm.
5. Diverticulosis without evidence of acute diverticulitis.
Brief Hospital Course:
Patient Admitted with R sided abdominal pain s/p loop colostomy.
CT scan was done showing possible abscess. Iintravenous
antibiotics started as well as intravenous fluids. Labs were
obtained and monitored. Initial labwork showed elevated bun/cre.
confirming acute renal failure. Also white count was elevated.
Throughout hospital course patient's pain resolved and her acute
renal failure resolved. We will send her home today with one
week of cipro/flagyl. We also will have her follow up with Dr.
[**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
Percocet prn, Protonix 40', Atenolol 50', Nifedipine 60',
Lasix 20'
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*7 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Acute renal failure and abdominal pain
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - Please call [**Telephone/Fax (1) 2723**] to make an
appointment two weeks after discharge.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2158-3-2**] 8:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2158-3-2**] 8:00
Completed by:[**2158-1-24**]
|
[
"V44.3",
"V15.82",
"567.22",
"276.8",
"753.12",
"E878.8",
"585.9",
"562.10",
"403.90",
"584.5",
"276.51",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4124, 4195
|
3104, 3643
|
388, 395
|
4278, 4278
|
1938, 3081
|
5233, 5681
|
1418, 1434
|
3762, 4101
|
4216, 4257
|
3669, 3739
|
4423, 5210
|
1449, 1919
|
274, 350
|
423, 1228
|
4292, 4399
|
1250, 1282
|
1298, 1402
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,089
| 167,408
|
23894
|
Discharge summary
|
report
|
Admission Date: [**2179-3-2**] Discharge Date: [**2179-3-9**]
Date of Birth: [**2105-6-28**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Verapamil / Salmeterol / Tiotropium /
Nystatin / Tricor / Flovent Hfa
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
altered mental status, septic shock
Major Surgical or Invasive Procedure:
central venous line placement
History of Present Illness:
Pt is a 73yo male with PMH of chronic systolic CHF (EF 25%), s/p
dual chanmber pacer/[**First Name3 (LF) 3941**] implantation for a-fib with tachy-brady
syndrome, DM2 not on insulin, HTN, who was BIBEMS for altered
mental status. The patient reports that he simply felt weak and
"off balance." He states these symptoms have been going on for
some time (weeks). He denies any vertigo or diplopia. No fevers
but endorses some chills and myalgias. No chest pain or
palpitations. He endorses a new cough and a dry itchy throat, as
well as congestion. He does have a positive sick contact in that
his wife has "a cold." He has had a somewhat depressed appetite
and did vomit his food earlier today. No abdominal pain or
diarrhea. He denies dysuria prior to having a Foley placed in
the ED.
.
In the ED initial VS were 102.4 105 126/59 23 97% 2L. FSG was in
the 30s. He received 1 amp D50 and looked better, with sugars up
to 100s. Once euglyemic, he had no complaints and was very
interactive. Initial labs revealed elevated lactate to 8.1, with
AG was elevated at 21. A sepsis CVL was placed and infectious
workup was initiated, which revealed no leukocytosis or
bandemia. He had a clean U/A and a CXR which showed patchy
opacities within both lung bases. Blood and urine cultures were
sent and he received vanc/zosyn. His glucose again dropped to 21
for which he received another amp of D50 and was started on a D5
gtt. Despite this he remained hypoglycemic in the 30s and
received additional amp of D50 prior to ICU admission. A repeat
lactate after 3L IVF was 4.4 --> 3.3. A CVP was not transduced.
SvO2 monitoring revealed central venous O2 sats in mid 50's, but
dobutamine not started given concern for promoting tachycardia.
Most recent vitals prior to ICU transfer 107 122/86 20 99% 6L
NC.
Past Medical History:
# chronic systolic CHF (LVEF 25%)
# s/p dual chanmber pacer/[**First Name3 (LF) 3941**] implantation [**2178-6-18**] for
tachy-brady
syndrome with syncopal episode
# atrial fibrillation on coumadin
# Type II DM
# CRI - baseline Cr 1.1-1.5
# HTN
# asthma/COPD
# Gout - confirmed by arthrocentesis [**6-/2178**]
# obesity
# IBS
# elevated LFTs - thought [**3-15**] congestive hepatopathy
# PVD - s/p bilateral common iliac artery angioplasty and right
common iliac artery stenting in [**2176**]
Social History:
Lives with wife. Retired construction worker and former soldier.
Smoked 1 [**2-12**] ppd for 40 years and quit in [**2153**]. No other drugs
or alcohol.
Family History:
Family history is significant for 12 brothers and sisters who
have DM and HTN. Brother had MI in his 30's. No CA
Physical Exam:
VS - 98.7 93 101/66 22 98% RA
Gen: elderly somewhat dissheveled male in NAD. Oriented x3.
HEENT: NCAT. PERRL, EOMI. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple
CV: irreg irregular, normal S1, S2. No m/r/g.
Chest: Resp unlabored, no accessory muscle use.
+expiratorywheezing.
Abd: obese, soft, NTND. No tenderness.
Ext: 2+ edema b/l. Pt with black eschars and ulcerations on hand
and feet (chronic)
Skin: stasis dermatitis with erythematous changes over shins;
dressing on R great toe c/d/i.
Pertinent Results:
[**2179-3-2**] 04:25PM BLOOD WBC-9.2 RBC-4.76 Hgb-9.8* Hct-32.2*
MCV-68* MCH-20.5* MCHC-30.3* RDW-22.8* Plt Ct-242
[**2179-3-2**] 04:25PM BLOOD Neuts-86* Bands-0 Lymphs-12* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-62*
[**2179-3-2**] 04:25PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-2+ Polychr-2+ Ovalocy-1+ Target-2+
Burr-1+ Acantho-1+ Fragmen-1+
[**2179-3-2**] 04:25PM BLOOD Glucose-68* UreaN-24* Creat-1.3* Na-136
K-4.4 Cl-96 HCO3-19* AnGap-25*
[**2179-3-2**] 04:25PM BLOOD ALT-31 AST-88* LD(LDH)-560* CK(CPK)-78
AlkPhos-240* TotBili-2.9*
[**2179-3-3**] 12:54AM BLOOD ALT-41* AST-129* AlkPhos-221*
TotBili-2.7*
[**2179-3-2**] 04:38PM BLOOD Glucose-72 Lactate-8.1* Na-136 K-4.0
Cl-96*
[**2179-3-2**] 07:30PM BLOOD Glucose-24* Lactate-4.1*
[**2179-3-2**] 09:37PM BLOOD Glucose-30* Lactate-3.3*
[**2179-3-3**] 01:11AM BLOOD Glucose-30* Lactate-2.8*
Brief Hospital Course:
Patient is a 73 yoM with h/o CAD, systolic CHF (EF 20%), s/p
pacer and [**Month/Day/Year 3941**], presents with fever, hypoglycemia, possible
sepsis.
.
#. Shock, possibly septic - evidence of hypoperfusion with
lactate peak in ED of 8.1, improving to 4.1-->3.3 with fluids.
Unclear etiology but most likely source at this point appears
pulmonary, either viral or bacterial. The patient was managed on
broad spectrum antibiotics, but did not improve, requiring
escalating support, until the decision for CMO status. Care was
withdrawn at the direction of his HCP and family in a meeting
with the ICU team and he was placed on a morphine drip.
.
# Hypoglycemia - likely from ongoing sepsis, but contributions
from medication effect and poor hepatic/renal clearance of oral
hypoglycemics vs. impaired hepatic gluconeogenesis are also
possible.
.
#. CAD s/p MI: No evidence of ischemia on EKG. One set of
enzymes were negative int he ED but pt never complained of any
chest pain.
.
#. chronic systolic CHF: did not appear to be in florid
decompensated CHF at this time. He reported only mild SOB, and
CXR did not reveal evidence of pulmonary edema. All
antihypertensives were held.
.
#. A-fib. Pt was rate controlled with metoprolol and
anti-coagulated on coumadin prior to admission. Pt also has a
pacer for tachy/brady. Monitored on telemetry.
.
# Microcytic Anemia: severely microcytic with MCV 68, with 62
nRBCs on diff. Recent Fe studies did not reveal iron deficiency.
On that admission there was also no evidence of hemolysis.
.
# Elevated LFTs: The patient has had chronically elevated LFTs
and currently they are not significantly changed from prior.
Felt likely secondary to congestive hepatopathy versus
medication induced (was on amiodarone until recently)
.
#. CRI - baseline Cr 1.1-1.5: Pt with Cr 1.4 on admission.
Medications on Admission:
#. Albuterol Sulfate Inhaler [**2-12**] Inhalation every 4-6 hours
#. Allopurinol 100 mg PO DAILY
#. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
#. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
#. Lasix 80 mg Tablet PO twice a day.
#. Warfarin 1 mg and 2 mg alternating daily
#. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily) as needed.
#. Glyburide Micronized-Metformin 5-500 mg Tablet Sig: One (1)
Tablet PO once a day.
#. Lisinopril 5 mg PO once a day.
#. Mesalamine 250 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO three times a day.
#. Toprol XL 200 mg PO once a day.
#. Multivitamin Tablet PO once a day.
#. Vitamin B12 1,000 mcg Tablet PO once a day.
#. Omega-3 Fatty Acids
#. Omeprazole 40 mg PO twice a day.
#. Ferrous Sulfate 325 mg PO DAILY
#. Acetaminophen [**Telephone/Fax (1) 60938**] mg PO TID
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"285.9",
"493.20",
"443.9",
"403.90",
"274.9",
"570",
"276.2",
"585.9",
"428.22",
"412",
"427.31",
"785.52",
"V45.02",
"564.1",
"428.0",
"038.9",
"V58.61",
"250.80",
"995.92",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7323, 7332
|
4516, 6344
|
386, 417
|
7383, 7392
|
3614, 4493
|
7448, 7458
|
2944, 3058
|
7295, 7300
|
7353, 7362
|
6370, 7272
|
7416, 7425
|
3073, 3595
|
311, 348
|
445, 2239
|
2261, 2757
|
2773, 2928
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,261
| 100,848
|
17615
|
Discharge summary
|
report
|
Admission Date: [**2119-5-20**] Discharge Date: [**2119-6-1**]
Date of Birth: [**2045-6-9**] Sex: M
Service: CCU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
male with the diagnosis of ischemic cardiomyopathy who awoke
on the morning of admission and presented to an outside
hospital. He had previously been seen as an outpatient for
shortness of breath one week ago and was diagnosed with CHF
exacerbation at which time his Lasix dose had been doubled
and resulted in a 6 pound weight loss over two days.
Subsequently his urine output started to decline. In the
emergency room at the outside hospital he was given 80 mg IV
of Lasix which resulted in hypotension and tachycardia with
minimal urine output. He then received a normal saline bolus
which improved his blood pressure and heart rate. He was
then transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY: Coronary artery disease. History of
postoperative myocardial infarction after surgery. He has a
pacemaker placed in [**2113**] dual chamber placed after a
bradycardiac episode. Diabetes type 2 recently started on
glipizide. Peripheral vascular disease. Abdominal aortic
aneurysm status post repair. Colon cancer status post
resection and diverting colostomy in [**2084**]. Melanoma status
post resection. Congestive heart failure with EF of
approximately 15% attributed to ischemia.
Hypercholesterolemia. Renal insufficiency baseline
creatinine approximately 2 to 2.5. Status post right CEA.
Known 100% occluded left carotid artery.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lasix 40 mg p.o. q.d., Lipitor 40
mg p.o. q.d., captopril 12.5 mg t.i.d., Lopressor 50 mg
t.i.d., glipizide 2.5 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
amiodarone 200 mg p.o. b.i.d.
FAMILY HISTORY: Stomach cancer. History of rheumatoid
arthritis and coronary artery disease.
SOCIAL HISTORY: Ex-tobacco use, quit approximately 40 years
ago. No alcohol use. Used to work for the telephone
company.
PHYSICAL EXAMINATION: On admission vital signs were
temperature of 98.7, heart rate 115, blood pressure 114/60,
oxygen saturation 98% on 2 liters nasal cannula. In general,
an elderly male in no apparent distress. HEENT PERRL, EOMI,
MM dry, OP clear, poor dentition. Neck normal carotid
upstroke, bounding carotid pulses, engorged EJV with JVD up
to 10 cm, no thyromegaly, no lymphadenopathy. Chest diffuse
expiratory wheezes plus rales left greater than right half
way up lung fields. Heart tachycardiac, regular, [**4-6**]
holosystolic murmur heard best at the left lower sternal
border, left ventricular heave. Abdomen colostomy in place
without erythema, soft midline scar well healed, bowel sounds
positive. Extremities positive cyanosis bilateral lower
extremities, dopplerable pulses, 2 to 3+ pitting edema up to
mid-shin, no clubbing. Neuro alert and oriented times three,
grossly intact.
LABORATORY DATA: On admission white blood cell count 6.1,
hematocrit 37.4, platelets 163. Sodium 137, potassium 4.9,
chloride 99, CO2 20, BUN 103, creatinine 3.9, glucose 138.
Magnesium 2.7, phosphate 5.4, calcium 9.4, albumin 3.4. ALT
36, AST 29, LK 294, LDH 352. CK 186, MB 7, troponin 0.08.
Urinalysis was clean. EKG was v-paced with 100% capture rate
of 115 with magnet rate of 60, sinus tachycardia with left
bundle branch block. Chest x-ray showed cardiomegaly with
preserved redistribution, no infiltrates, blunting of
costophrenic angle on right.
HOSPITAL COURSE:
1. Cardiac:
A. Ischemia. The patient was ruled out for myocardial
infarction. There were no ischemic issues during this
hospitalization.
B. Pump. The patient arrived in congestive heart failure
exacerbation. He was unable to be adequately managed with
Lasix and Bumex and required Natrecor for adequate diuresis.
Patient diuresed well. We were able to continue his beta
blocker, aspirin and statin as well as his ACE inhibitor.
His ACE inhibitor was switched from captopril to lisinopril
for more convenient once daily dosing.
C. Rhythm. The patient was found to be in a-fib on
admission. An echo to evaluate for possible cardioversion
showed an apical thrombus, thus, cardioversion was
contraindicated. He was started on heparin and Coumadin for
this thrombus with an INR goal of 2 to 3. Heparin was
discontinued prior to discharge when this goal was reached.
EP was also consulted and recommended discontinuation of
amiodarone as atrial fibrillation had occurred while on this
medication. In addition, low dose digoxin was added for
further rate control and augmentation of cardiac output.
2. Renal. The patient came in in acute on chronic renal
failure. This was felt to be secondary to heart failure
exacerbation with pre-renal failure. Creatinine peaked at
4.2 well above baseline of approximately 2.5. This then
subsequently decreased to approximately 2.8 where it stayed
for the remainder of the hospitalization and on discharge.
3. Of note, during attempted placement of a right subclavian
line, a large hematoma of his neck formed with tracheal
compression. Otolaryngology was consulted and did not feel
there was a risk of airway compromise. The hematoma slowly
improved without further management.
4. GI. Protonix was continued throughout hospitalization.
There were no GI issues.
5. Heme. The patient was started on Coumadin for atrial
fibrillation with apical thrombus. In addition, his
hematocrit declined and he needed to be transfused during the
hospitalization to maintain hematocrit above 28 as he has
known heart failure and coronary artery disease.
DISCHARGE STATUS: The patient was discharged to acute rehab
as he was significantly decompensated from this
hospitalization and heart failure exacerbation.
DISCHARGE INSTRUCTIONS: During rehab at home he should
closely follow his 2 gm sodium diet and fluid restriction to
less than 2 liters per day as well as he should weigh himself
daily and if there is a gain of greater than 1 kg or any new
shortness of breath or increased lower extremity edema, his
cardiologist or PCP should be [**Name (NI) 653**] immediately for
management to reduce the risk of further congestive heart
failure exacerbation requiring hospitalization.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Sublingual nitroglycerin 0.3 mg p.r.n.
4. Lipitor 40 mg p.o. q.d.
5. Digoxin 0.125 mg p.o. q.d.
6. Epoetin alfa 5000 units subcu q.week.
7. Toprol XL 100 mg p.o. q.d.
8. Lisinopril 5 mg p.o. q.d.
9. Warfarin 3 mg p.o. q.h.s.
10. Glipizide 2.5 mg p.o. q.d.
11. Salmeterol inhaler one to two puffs b.i.d.
12. Lasix 40 mg p.o. q.d.
13. Trazodone 50 mg p.o. q.h.s. p.r.n.
DISCHARGE DIAGNOSES:
1. CHF exacerbation.
2. Atrial fibrillation.
3. Apical thrombus.
4. Acute on chronic renal failure.
5. Diabetes type 2.
6. COPD.
7. Coronary artery disease.
8. Peripheral vascular disease.
9. Anemia thought to be secondary to renal failure.
CONDITION ON DISCHARGE: He was discharged in stable
condition to rehab.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 18032**]
MEDQUIST36
D: [**2119-5-31**] 13:12
T: [**2119-5-31**] 13:03
JOB#: [**Job Number 49066**]
|
[
"272.0",
"584.9",
"428.0",
"427.31",
"414.8",
"496",
"998.12",
"428.23",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
1852, 1931
|
6757, 7008
|
6299, 6736
|
1653, 1835
|
3542, 5803
|
5828, 6276
|
2079, 3525
|
152, 174
|
203, 921
|
944, 1626
|
1948, 2056
|
7033, 7365
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,059
| 136,343
|
41620
|
Discharge summary
|
report
|
Admission Date: [**2138-12-16**] Discharge Date: [**2138-12-25**]
Date of Birth: [**2062-3-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 y/o M with metastatic NSCLC with brain metastasis s/p
resection and WBRT who has received no systemic therapy due to
poor performance status who presented with complaints of
increased SOB. The patient is a poor historian due to
difficulty with memory, but per nursing home report his symptoms
started one day prior to admission. He complained of increased
cough, SOB, at least one episode of small amount of hemoptysis
and chest pain, and per ER note subjectove fevers. Pt was
transferred to the ER at [**Hospital1 18**] where he was found to have a new
oxygen requirement. CT of the chest was negative for PE but did
show progression of disease with increased LUL perihilar mass,
satellite lesions, endobronchial involvement of LUL and LLL
small pleural effusion. The patient received Cefepime, Vanco
and Levofloxacin in the ER due to concern for pneumonia.
Currently, he reports cough, no fevers, chills, no SOB (on
Oxygen).
ROS was positive for pain when urinating, but other systems were
negative as below.
Review of systems:
Constitutional: No weight loss/gain, fevers, chills, rigors
HEENT: No blurry vision, diplopia, loss of vision, photophobia.
No dry motuh, oral ulcers, bleeding nose or [**Male First Name (un) **], tinnitus, sinus
pain.
Cardiac: No chest pain, No palpitations, LE edema, + DOE.
Respiratory: see HPI
GI: No nausea, vomiting, abdominal pain, diarrhea, constiatpion
Heme: No bleeding, bruising.
Lymph: No lymphadenopathy.
GU: No incontinence, urinary retention,+ dysuria, no hematuria,
Skin: No rashes, pruritius.
Endocrine: No change in skin or hair.
MS: No myalgias, arthralgias, back or nec pain.
Neuro: No numbness, weakness or parasthesias. No dizziness,
lightheadedness. No headache.
Psychiatric: No depression, anxiety.
Allergy: No medication allergies.
Past Medical History:
Metastatic NSCLC diagnosed [**9-/2138**] with mets to brain s/p
resection and WBRT
HTN
Prostate CA s/p seed treatment and chemotherapy in [**2134**] with a
urologist at [**Hospital3 **]
GERD
ONCOLOGIC HISTORY:
[**2138-10-6**] in the setting of acute confusion, the patient
presents, found to have a large left frontal cystic lesion,
associated edema, given Decadron and transferred to [**Hospital1 **].
[**2138-10-7**] CT torso revealed a 4 x 4 x 3.5 cm left perihilar
mass with associated lymphadenopathy in the left hilum and
mediastinum with a large left hilar lymph node measuring 2.2 cm,
suspicious pretracheal lymph nodes, left hilar and satellite
lesions, renal calculus.
[**2138-10-7**] MRI head revealed peripherally enhancing mass 3.9 x
2.8 x 3.4 cm with edema, left cerebellar 8 x 10 x 8 peripherally
enhancing lesion, also 7-mm focus in the medial temporal lobe
and small right caudate lesion.
[**2138-10-10**] left-sided craniotomy of large left-sided high
parietal lesion with Dr. [**Last Name (STitle) **]. Pathology revealed metastatic
carcinoma consistent with lung primary. EGFR pending, ALK
rearrangement negative, KRAS wildtype.
Postoperative MRI consistent with surgical site changes.
[**2138-10-31**] to [**2138-11-11**] WBRT with Dr.[**Last Name (STitle) 3929**] 20 Gy.
[**2138-12-8**], bone scan negative for metastatic disease. Brain
MRI reveals reduction in size of left cerebellar metastatic
lesion and likely the right caudate, may be related to
treatment, although his neurologist, Dr. [**Last Name (STitle) 6570**] was concerned
for a small lesion in the right frontal lobe.
Social History:
He is a right handed Creole man. His family reports that he was
a marine and worked in metal welding. He has a long history of
Tobacco use 1ppd but now smoke about 10 cigarettes daily.
He has a son here in [**Name (NI) 86**] in [**Name (NI) 1468**] with three children. He
has a daughter in Montreal, [**Name (NI) 6607**] and he has other children
(total 11) as well as an ex-wife back in [**Country 2045**].
Family History:
unknown
Physical Exam:
VS T current 98.6 BP 131/82 HR109 RR 18 O2sat
99% 3LNC 92%RA
Gen: In NAD, pleasant
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes dry. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally anteriorly, slightly diminished BS L
base, no wheezes, rales, rhonchi. Normal respiratory effort.
CV: tachycardic, regular, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 1, CN II-XII grossly intact.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
[**2138-12-16**] 07:00PM WBC-9.0 RBC-4.43* HGB-11.8* HCT-36.8* MCV-83
MCH-26.7* MCHC-32.2 RDW-16.3*
[**2138-12-16**] 07:00PM NEUTS-82.7* LYMPHS-11.9* MONOS-4.2 EOS-0.8
BASOS-0.4
[**2138-12-16**] 07:00PM PT-13.7* PTT-29.5 INR(PT)-1.3*
[**2138-12-16**] 07:00PM GLUCOSE-212* UREA N-17 CREAT-0.7 SODIUM-127*
POTASSIUM-5.6* CHLORIDE-87* TOTAL CO2-32 ANION GAP-14
[**2138-12-16**] 07:00PM CALCIUM-9.7 PHOSPHATE-2.8 MAGNESIUM-1.9
[**2138-12-16**] 07:22PM LACTATE-2.5* K+-5.7*
[**2138-12-16**] 08:13PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2138-12-16**] 09:59PM LACTATE-1.1
[**2138-12-16**] 08:13PM URINE RBC-3* WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
.
[**2138-12-20**] pCXR: IMPRESSION: AP chest compared to [**12-17**] and
8:
Pulmonary edema seen best in the right lung has progressed to
moderately severe. There is some reexpansion in the apex of the
previously entirely collapsed left lung. Large left hilar mass
and moderate left pleural effusion have increased since [**12-16**]. Distention of the azygos vein could be due to biventricular
heart failure, but possibility of new concurrent pericardial
effusion should be kept in mind. No pneumothorax.
.
[**2138-12-18**] CXR: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Subtotal opacification of the left
hemithorax. On the right, pre-existing areas of mild opacities
are minimally progressive. The right aspect of the heart border
is unchanged.
.
[**2138-12-17**] CXR IMPRESSION: Progression of left lung white-out
likely total lung collapse, underlying known lung and hilar
pathology is obscured
.
[**2138-12-16**] CXR: IMPRESSION: Increased size of left upper
lobe/perihilar mass compatible with known malignancy.
Moderate-sized left pleural effusion with left basilar opacity
likely reflecting atelectasis. Mild pulmonary vascular
congestion.
.
[**2138-12-16**] Head CT w/o contrast: IMPRESSION: Post-surgical changes,
stable in appearance, without acute intracranial abnormality.
Known left cerebellar metastasis is not clearly visualized,
though the right inferior frontal lobe metastasis appears
unchanged. No new mass lesions are seen, though MRI is more
sensitive for the evaluation of intracranial metastatic disease.
.
[**2138-12-16**] CTA: IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Significant interval progression of a left upper lobe hilar
mass with new bronchial obstruction and likely endobronchial
involvement with post obstructive left lower lobe collapse
and/or infection. New small left effusion. Increased extent of
satellite metastases within bilateral lungs and mediastinal
adenopathy.
3. Background emphysema.
4. New sclerotic lesion in T9 vertebral body, concerning for
metastasis. Unchanged left T5 laminar sclerotic lesion.
Brief Hospital Course:
76 y/o male (Haitan creole only speaking) nursing home patient
oriented only to his name at baseline admitted with hypoxemia
and hemoptysis due to progression of his primary NSCLC with
concomittant progression of brain metastases. His initial brain
metastatsis was treated with neurosurgical resection in
[**2138-9-11**] followed by WBRT. Since diagnosis of brain mets
he has never regained the ability to perform activities of daily
living and spends most of his time in bed at his nursing home.
Because of his poor performance status, he was not a candidiate
to receive treatment to his primary tumor. Following admission,
he was treated with supplemental oxygen and started on
levofloxicin. He was evaluated by radiation oncology on hospital
day one and began the first of five palliative radiation
fractions to his lung to control hemoptysis(400 cGy per fraction
for total dose of [**2127**] cGy). His course was notable for
overnight transfer on [**2138-12-17**] to the intensive care unit for
transient worsening of his hypoxemia and white out of his left
lung. He was treated with broadening of his antibiotis and made
an overnight recovery consistant with mucous plugging. In the
ICU, he was noted to nonsustained runs up to 20 beats of
ventricular tachycardia. He was monitored on telemetry and his
electrolytes were aggressively repleted. After long discussions
with the patient's son, [**Name (NI) **], who is also his health care
proxy, the patient was made DNR/DNI on [**2138-12-20**] with the plan to
continue to treat any reversible medical problems but to focus
on the patient's symptoms and forgo any further ICU transfers.
Telemetry was therefore discontinued. In this setting, The
patient developed recurrent episodes of tachycardia, tachypnea,
and hypertension with transient evidence of congestive heart
failure (CHF) that were treated symptomatically with IV
metoprolol, morhpine, lasix, +/- nebulizers. He continued to
have hemoptysis but did not require blood transfusions and
respiratory status had stabilized. Palliative service had
followed the patient adn family and hospice services offered. At
this time patinet defers hospice care but ubderstand that in teh
near future pt will benefit from the support of hospice.
# Tachycardia and Tachypnea/hypoxia/CHF: No findings of PE on
CTA on admisttion. Likely component of postobstructive
pneumonia, CHF and progressive lung ca. Given his goals of care,
he was treated symptomatically with O2 by nasal cannula and
shovel mask. Morphine 1-2 mg prn Q2H or more frequently if
needed. Metoprolol IV as tolerated. Lasix 20 mg prn. Scheduled
Nebulizers and prn. Pt stabilized and 72 hrs prior to d/c did
not require IV morphine or IV lasix. Pt started on scheduled
oral metoprolol with good tolerance and better heart rate
control.
.
.
# HTN: HCTZ held on admission due to hypovolemia at
presentation. Amlodipine also d/c due to hypotension. Added po
metoprolol as scheduled since this has relieved his episodes of
tachycardia and his tachypnea and hypertension. PRN IV
metoprolol was also given.
.
# NSVT: telemetry DC'd [**2138-12-20**] in light of goals of care.
Electrolytes were followed and repleted as needed.
.
# Progressive metastatic NSCLC: He was not a candidate for
systemic therapy due to his poor performance status. In the
setting of pulmonary progression with resulting hemoptysis and
assymptomatic brain metastases, there was no clear utility to
further XRT to the small assymptomatic brain met was
discontinued. Since he is clinically stable, radiation to his
primary lung tumor to control hemoptysis and possibly relieve
post obstructive symptoms offered the greater palliation than
interventional pulmonary procedure. Started palliative radiation
on [**2138-12-17**].
.
# Hemoptysis: Due to progression of primary lung cancer.He
remained hemodynamically stable and was treated with palliative
radiation.Pt may develop radiation esophagitis and will need
supportive care ( pain meds, sucralfate, oncology magic mix)
.
# Post obstructive pneumonia: Supplemental oxygen. Began
vancomycin and zosyn IV in the ICU and completed 7 days .Pt d/c
with additional 4 days of flagyl.
.
# Brain metastases: Continued Keppra 750 mg [**Hospital1 **].No evidence of
increased edeam on head CT this admission.
.
# Encephalopathy/Delirium: Baseline confusion due to his
underlying neurologic compromise following his neurosurgery.
.
# Hyponatremia and dehydration: Present on admission due to
hypovolemia due to poor po intake. Resolved with IVF.
.
# Hyperglycemia: Continued on insulin sliding scale.
.
#Hypercalcemia: Mild, likely due to volume depletion. Resolved
after holding diuretics.
.
#Urinary incontinence: Pt had a foley cath placed during
hospital stay for close monitoring of volume status when he was
hemodynaomically unstable.Foley d/c priori to d/c . Pt was able
to void but was incontinent.Urine output should be monitored
closely.
.
# GERD: continued on proton pump inhibitor.
Code status: Pt was transitioned to DNR/DNI during the hospital
stay.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg
Capsule - 1 Capsule(s) by mouth twice a day hold SPB <100
LEVETIRACETAM - (Prescribed by Other Provider) - 750 mg Tablet
-
1 Tablet(s) by mouth twice a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
TAMSULOSIN - (Prescribed by Other Provider) - 0.4 mg Capsule,
Ext Release 24 hr - 1 Capsule(s) by mouth daily at bedtime
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5
(One half) Tablet(s) by mouth as needed for insomnia
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) - 325
mg Tablet - 2 Tablet(s) by mouth as needed for every 6 hours
pain or temp
BISACODYL - (Prescribed by Other Provider) - 5 mg Tablet,
Delayed Release (E.C.) - 2 Tablet(s) by mouth daily bedtime
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
400 unit Capsule - 2 Capsule(s) by mouth daily
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
INSULIN REGULAR HUMAN - (Prescribed by Other Provider) - Dosage
uncertain
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA CONCENTRATED] -
(Prescribed by Other Provider) - Dosage uncertain
SENNOSIDES - (Prescribed by Other Provider) - 8.6 mg Tablet - 1
Tablet(s) by mouth daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
4. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. insulin regular human 100 unit/mL Solution Sig: Two (2)
Injection ASDIR (AS DIRECTED): per sliding scale.
7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 5 days.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 5 days.
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours as needed for weight gain above 3 pounds
/increased edema/increased sob.
16. morphine 10 mg/5 mL Solution Sig: [**5-20**] PO every six (6)
hours as needed for pain/sob.
17. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**1-12**] Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
18. sucralfate 100 mg/mL Suspension Sig: Ten (10) ml PO four
times a day as needed for epigastric pain/esopgagitis.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Progressive metastatic lung cancer
Shortness of breath
Hypoxemia (low oxygen)
Hemoptysis (coughing blood)
Pneumonia
Non sustained ventricular tachycardia
Congestive heart failure
Confusion
Brain metastasis
Bone metastasis
Hypertension (high blood pressure)
Heart burn
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr [**Known lastname 17862**] was admitted for pneumonia and coughing up blood due
to progression of the lung cancer. He was treated with oxygen,
antibiotics and radiation therapy. After discussions Mr
[**Known lastname 90469**] son and health care proxy, [**Name (NI) **], code status was
changed to DNR/DNI. Mr [**Known lastname 17862**] had episodes of a fast heart rate
that caused your breathing to worsen. These were treated with
morphine and medication to slow your heart rate. These epides
resolevd priori to discharge.
.
The following changes were made to your medications:
STOP hydrochlorathiazide
Followup Instructions:
Please contact Dr [**Name (NI) **] for any concerns.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2139-1-13**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2139-1-13**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"92.29"
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icd9pcs
|
[
[
[]
]
] |
16201, 16278
|
7826, 12866
|
327, 334
|
16590, 16590
|
4958, 7803
|
17401, 18088
|
4250, 4259
|
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|
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16767, 17378
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|
268, 289
|
362, 1382
|
16605, 16743
|
2196, 3806
|
3822, 4234
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,254
| 181,321
|
47966
|
Discharge summary
|
report
|
Admission Date: [**2195-11-10**] Discharge Date: [**2195-11-13**]
Date of Birth: [**2134-9-9**] Sex: F
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
59F h/o presents with SOB.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 59F h/o ESRD on HD [**2-21**] IgA nephropathy s/p failed cadaveric
transplant, malignant HTN complicated by seizures, diastolic
CHF, Afib, h/o medical non-complaince presents with SOB.
.
The patient receives HD 3x per week, last session was Saturday.
Sunday she felt more fatigued in the AM, but was able to work
12-6pm and perform physical labor. Ate dinner of fried fish
around 8pm and took all of her medications (reports no lapses
recently). At 10pm, she went to bed and noted a 'gurgling'
sensation in her chest/throat with fluid 'dripping from her
mouth' that she has had before with CHF exacerbations. While she
usually only uses 1 pillow at night, she had to sit nearly
upright to fall asleep. She awoke 1 hour later with SOB acutely
and called 911. Denies associated CP or nausea, but did feel
diaphoretic. No recent PND or peripheral edema. Of note, her BP
regimen was recently simplified [**9-28**] from 4 agents to only
toprol XL and diltiazem ER, and she wonders if her BP is being
effectively controlled.
In the ED, afebrile, 200/100, 90, 100% on NRB. Labs notable
normal CK, trop at baseline, BNP>[**Numeric Identifier **]. ECG with ? ST segment
changes in V1,2 thought to be due to J-point elevation. CXR
showed mild congestion consistent with CHF although PNA could
not be excluded. Started on nitro gtt, and also given ASA 325
and tylenol for ?PNA. Renal consulted from ED, no emergent need
for dialysis, planned for AM. Admitted for CHF, hypertensive
urgency.
.
Currently SOB completely resolved. Notes headache that coincided
with initiation of nitro gtt in the ED. No nausea, CP,
diaphoresis, or other complaints.
Past Medical History:
Past Medical History:
1. ESRD secondary to IgA nephropathy in [**2169**] s/p renal
transplant [**2173**] with acute on chronic rejection, resumed HD
[**1-25**]; per priro renal notes, there may have been a component of
non-compliance with immunosupression meds
2. Malignant HTN complicated by seizures ([**5-26**]) not on
anti-epileptics and seizure free since this time; denies h/o CVA
3. Depression
4. Rheumatic fever in childhood
5. Diastolic CHF
6. Afib (recently diagnosed [**9-28**], not on coumadin)
7. h/o bleeding duodenal ulcer
Social History:
Social History: Single, never married British female with no
children. Lives alone in her own apartment with cats. No family
in the area and few social supports. Has 2 sisters, one in
[**Location (un) **] she speaks with infrequently and one in [**Country 26467**] from
which she is estranged. Former smoker. Denies current tobacco,
EtOH, illicits. Works part-time as asst coffee shop manager.
Family History:
Family History:
Father died age 80.
Mother with lung Ca, died @64.
Many aunts/uncles with Ca.
Sister with breast Ca, survived.
No family hx renal problems.
Physical Exam:
Physical Exam:
T HR BP RR SaO2 Weight
General: WDWN, NAD, breathing comfortably on RA
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR, s1s2 normal, no m/r/g, JVP 8cm
Pulmonary: Bibasilar crackles (R>L), no wheeze
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema, left AV fistula
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities, no focal deficits noted
Pertinent Results:
[**2195-11-10**] 10:10PM CK(CPK)-57
[**2195-11-10**] 10:10PM cTropnT-0.18*
[**2195-11-10**] 01:46PM CK(CPK)-84
[**2195-11-10**] 01:46PM CK-MB-NotDone cTropnT-0.23*
[**2195-11-10**] 09:24AM CK(CPK)-71
[**2195-11-10**] 09:24AM CK-MB-NotDone cTropnT-0.20*
[**2195-11-10**] 04:10AM LACTATE-1.3
[**2195-11-10**] 02:05AM GLUCOSE-95 UREA N-95* CREAT-11.9*# SODIUM-138
POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-26 ANION GAP-24*
[**2195-11-10**] 02:05AM estGFR-Using this
[**2195-11-10**] 02:05AM CK(CPK)-85
[**2195-11-10**] 02:05AM cTropnT-0.07*
[**2195-11-10**] 02:05AM CK-MB-NotDone proBNP-GREATER TH
[**2195-11-10**] 02:05AM CALCIUM-9.1 PHOSPHATE-6.6* MAGNESIUM-2.6
[**2195-11-10**] 02:05AM WBC-10.8 RBC-3.60* HGB-11.9* HCT-36.0
MCV-100* MCH-33.1* MCHC-33.1 RDW-15.1
[**2195-11-10**] 02:05AM NEUTS-74.5* LYMPHS-17.4* MONOS-3.5 EOS-3.9
BASOS-0.7
[**2195-11-10**] 02:05AM PLT COUNT-271
[**2195-11-10**] 02:05AM PT-14.1* PTT-26.8 INR(PT)-1.2*
ECG: sinus, 85bpm, LVH w/ repolarization V1-3, TWI I/AVl,
similar to prior tracing except ST changes V1-3 are slightly
more pronounced
.
CXR: *prelim* prominent vascular markings with ?slight increase
in right base opacity compared to [**2195-8-31**], improved left lung
aeration
.
Prior studies -
.
Echo ([**3-28**]): The left atrium is mildly dilated. The right atrial
pressure is indeterminate. There is moderate 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%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion.
Brief Hospital Course:
A/P: 59F h/o ESRD on HD [**2-21**] IgA nephropathy s/p failed cadaveric
transplant, malignant HTN complicated by seizures, diastolic
CHF, Afib, h/o medical non-compliance presented with SOB and
hypertensive urgency. BP's and SOB normalized after dialysis x2
and patient was discharged home in stable condition.
.
# CHF: Diastolic. EF>55% on [**3-28**] echo. Euvolemic on discharge.
Exacerbation likely due to dietary indiscretion. Also h/o med
noncompliance although denies currently and seems reliable.
Severe HTN contributed to exacerbation. Patient was started on
a nitro gtt and place on oxygen on arrival to the ICU, both of
which were quickly weaned. During hemodialysis 3L of fluid
taken off with subsequent resolution in respiratory symptoms.
Repeat dialysis removed an additional 2.2 kg.
.
# Hypertensive urgency: History of med noncompliance and HTN
emergency complicated by seizures. BP 200/100 in the ED without
focal symptoms, improved on nitro gtt. Question of ECG changes
although appear to be consisent with priors and no other
symptoms consistent with angina. Cardiac enzymes were cycled,
and she received morphine PRN for pain serial ECGs, and fluid
and Na restricted diet with monitoring of both. Nitro gtt
weaned as pt transitioned to her home medications. Second round
of HD further improved BPs to 130-150 which is the patient's
baseline pressures. She was discharged on her home medications
of Toprol XL, Diltiazem ER and a new medication of Lisinopril
20mg.
.
# ESRD: Due to IgA nephropathy s/p failed transplant. On HD as
outpatient, TuThSat, Dr. [**First Name (STitle) 805**] is nephrologist. Does not
produce urine. Renal consulted in ED, and received HD the
morning after presentation and then on out patient schedule.
Continued home renal regimen. Patient to return to regular
dialysis schedule upon discharge. Per renal, an additional
0.5kg was removed while in-patient and they suspect patient
needs to be at a slightly lower dry weight.
.
# Headache: Likely due to nitro gtt and temporally coincided and
worsened with improved control of HTN. No other neurologic
symtpoms. Resolved prior to discharge.
.
# Afib: Stroke risk factors include HTN, currently on ASA 325
daily. Could consider coumadin as likely beneficial, however
defer to outpatient providers. Also has h/o bleeding duodenal
ulcer.
.
# Code Status: DNR/DNI per patient.
Medications on Admission:
Renagel 2400 tid w/ meals
Protonix 40 daily
ASA 81 daily
Phoslo 667 [**Hospital1 **] w/ meals
Sensipar at dinner ?dose
Toprol XL qhs ?dose
Diltiazem ER ?dose
Discharge Medications:
1. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO BID
WITH BREAKFAST, LUNCH ().
4. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
CHF Exacerbation
.
End Stage Renal Disease [**2-21**] IgA Nephropathy
Atrial Fibrilaltion
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with hypertensive urgency and a heart failure
exacerabation to the intensive care unit. You were treated
there with dialysis and your breathing difficulty resolved. You
were transferred to the general medical floor where your blood
pressure came back down to your baseline. You were also
continued on your home blood pressure medication.
.
No medication changes were made. You should continue taking all
your home medications as directed.
.
You should continue your regular dialysis schedule of Tuesday,
Thursday, Saturday.
.
If you have shortness of breath, fever, chest pain or other
concerning symptom, please seek medical care immediately.
.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
Please follow up with your PCP as necessary.
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9106, 9112
|
5760, 8138
|
297, 303
|
9266, 9275
|
3674, 5737
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231, 259
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331, 1973
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2017, 2534
|
2566, 2946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,421
| 159,286
|
2340+2341+2345+2349
|
Discharge summary
|
report+report+report+report
|
Unit No: [**Numeric Identifier 12182**]
Admission Date: [**2116-6-1**]
Discharge Date: [**2116-8-4**]
Date of Birth:
Sex:
Service:
HISTORY OF PRESENT ILLNESS: On admission, the patient is a
77 year old male who was found by his wife this afternoon
laying in bed and incontinent. After stimulating Mr. [**Known lastname 12183**],
she was able to wake him and he walked to the bedroom closet
where he voided on the floor, stating he was in the bathroom.
He was last seen by wife at approximately 9:30 a.m. when he
dropped her off at work. He did not show up at lunch that
noon. Mr. [**Known lastname 12183**] has complained of headaches and left retro
orbital pain for the last three to four days. Mr. [**Known lastname 12183**] has
had episodes of epistaxis for which he has been cauterized
and placed on antibiotics.
PAST MEDICAL HISTORY: Non insulin dependent diabetes
mellitus. Hypertension. Atrial fibrillation. Carotid
stenosis. Gout. Chronic obstructive pulmonary disease.
Thyroid cancer, which he had resected in [**2114**]. Mitral valve
replacement.
MEDICATIONS ON ADMISSION:
1. Levoxyl .75 mg.
2. Multi-vitamin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is retired from the [**Company 2318**] and he lives
with his wife.
LABORATORY DATA: On admission, his laboratory studies show a
white blood cell count of 7.4. Hematocrit is 43.2 and
platelets are 81. PT is 13.1; PTT is 22.2 and INR is 1.1.
Sodium is 139; potassium of 4.5. BUN is 14 and his
creatinine is 0.8. CK of 101. Troponin of .40. CK MB of 6.
PHYSICAL EXAMINATION: On physical examination, the patient's
vital signs were 173/83; pulse of 85; SPOT is 99 percent.
Head, eyes, ears, nose and throat showed no blood in his
nares. Heart showed a regular rate and rhythm. Lungs were
clear bilaterally. Abdomen was soft and nontender with bowel
sounds in all four quadrants. Extremities showed no edema.
Neurologically, he was awake but drowsy at times; oriented
times one; he could only recite his name. Repetition was
intact. He had no drift. He followed two step commands. He
had a right facial droop. No diplopia. Extraocular
movements intact. IP's and grips were [**4-29**]. Pupils were 2 mm
and slightly reactive bilaterally.
ASSESSMENT: 77 year old male with diffuse subarachnoid
hemorrhage and blood throughout, including intra ventricular
blood in fourth ventricle; cluster of blood around the left
carotid artery. The patient was only oriented to person.
Follows two step commands. Dr. [**First Name8 (NamePattern2) 6644**] [**Last Name (NamePattern1) 12184**] and [**First Name8 (NamePattern2) 3065**]
[**Last Name (NamePattern1) 3903**], nurse practitioner, examined the patient and spoke
at length with family of subarachnoid hemorrhage and
possibility of an aneurysm.
PLAN: At this time, he is to have a CTA. Nipride to titrate
blood pressure less than 130. A line. Type and cross for two
to six units and platelets. Will reassess with CTA.
Cervical spine films to rule out fractures.
ADDENDUM: Mr. [**Known lastname 12183**] has a 6 mm left internal carotid artery
aneurysm at the bifurcation of MCA by radiology. Dr. [**Last Name (STitle) 12184**]
notified and called Dr. [**Last Name (STitle) 1132**]. Will bring to angio suite in
a.m. for diagnostic carotid artery angiogram with possible
coiling. Discussed subarachnoid hemorrhage and aneurysm at
length with the family. Risks and benefits of the procedure
were discussed. Mrs. [**Known lastname 12183**] signed consent. Spoke with
cardiology regarding positive troponin. Recommended beta
blocker. Further work-up when stabilized. Will continue to
rule out laboratory studies.
HOSPITAL COURSE: The following day, on [**2116-6-2**], the
patient was awake to stimulation only. Prefers his eyes
closed. His neurologic examination continued to decline. He
was neurologically drowsy with a right sided hemiparesis.
CTA showed a complicated fusiform aneurysm and left internal
carotid artery. He was to go to angioscopy today for a
diagnostic and possibly coiling angiogram. The patient was
taken to the angioscopy suite and underwent placement of a
right ventricular drain for subarachnoid hemorrhage. The
procedure went without complication. His examination was
unchanged. The patient was intubated at that time. Following
angiography, the patient was sedated and intubated. He
wasn't following commands. He tried to localize upper
extremities and withdrew his lower extremities. Plan at that
time was to keep his blood pressure under 130; keep his
ventricular drain at 15 and was given Ancef for prophylaxis.
The following day, the patient was opening his eyes and
sticking out his tongue, following some commands, still with
a right hemiparesis. He was neurologically stable at that
time. Endocrine was consulted to deal with his thyroid
problem. [**Name (NI) **] was placed on Dilantin and his drain was kept at
15. That same day, cardiology was consulted. The patient
was extubated. The assessment of the patient in surgical
Intensive Care Unit was subarachnoid hemorrhage, status post
coiling of aneurysm. Cardiology notes his troponin is up and
he had electrocardiogram changes. There was a question as to
whether he had suffered an ischemic result. Electrocardiogram
was unlikely to be myocardial ischemia, elevated troponin may
represent demand ischemia in the setting of acute illness.
Back rupture myocardial infarction was extremely unlikely.
They recommended continuing a beta blocker and to add aspirin
if not surgically contraindicated.
Endocrine, on that day recommended he should continue on his
Levoxyl dose of 175 mg q. Day. Otherwise, there is no
endocrine intervention required. For the next several weeks,
the patient was neurologically stable. However, he did show
spikes of fever on the 12th and was cultured. He had blood
cultures done and cerebrospinal fluid cultures done. On
[**6-7**], his blood culture was preliminarily negative as well as
his cerebrospinal fluid culture being negative; however, this
was only a preliminary diagnosis.
DICTATION ENDED
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2116-8-3**] 17:29:53
T: [**2116-8-3**] 18:03:31
Job#: [**Job Number 12185**]
Unit No: [**Numeric Identifier 12182**]
Admission Date:
Discharge Date: [**2116-8-4**]
Date of Birth:
Sex:
Service:
ADMISSION DIAGNOSES: Diffuse subarachnoid hemorrhage with a
6 mm left internal carotid artery aneurysm.
DISCHARGE DIAGNOSES: Status post left internal carotid
artery aneurysm coiling on [**2116-6-2**].
HISTORY OF PRESENT ILLNESS: On admission, the patient
presented as a 77 year old male to the Emergency Department.
He was found by his wife, confused and lethargic. He has been
having headaches for three to four days. On admission, CTA
showed a subarachnoid hemorrhage, likely secondary to a 6 mm
aneurysm of the left internal carotid artery at the
bifurcation. At the time of admission, he was found to have
positive carotid and cardiac enzymes. Troponin of 0.4 on
admission.
PAST MEDICAL HISTORY: Non insulin dependent diabetes
mellitus. No medications. Hypertension. No medications.
History of atrial fibrillation. Carotid stenosis, 70 percent
right internal carotid artery blockage. Thyroid surgery.
Status post thyroid carcinoma. Gout. Chronic obstructive
pulmonary disease.
PAST SURGICAL HISTORY: He had a thyroidectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Levoxyl.
2. Colace.
3. Albuterol.
4. Multi-vitamin.
PHYSICAL EXAMINATION: Heart rate of 81; blood pressure
129/52. SPOT was 97 percent on four liters of nasal cannula.
He opened eyes to name. Didn't follow commands. He had a
right facial droop. Pupils were 2 mm, reactive bilaterally.
Tongue was midline.
LABORATORY DATA: White blood cell count of 7.8; hematocrit
of 32.8; platelets of 196. PT was 13.4; PTT 23.2. INR of
1.2. Gases were 7.51, 30, 133, 25, 2. CTA at the time of
admission showed a diffuse subarachnoid hemorrhage secondary
to a 6 mm aneurysm at the bifurcation of the left internal
carotid artery and left MCA; positive for intraventricular
bleed. Cervical spine x-rays were negative. The plan at that
time was for Mr. [**Known lastname 12183**] to have a diagnostic angiogram with
possible coiling. Attending physician was Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**].
HOSPITAL COURSE: On [**2116-6-2**], the patient was given a
ventricular drain to relieve pressure of his subarachnoid
hemorrhage. He was on 25 mg of Fentanyl. He was prepped and
draped and drain was placed for 7 cm. There were no
complications. The patient was intubated and prepped for
angiogram the following day. The patient was admitted to
surgery. Attending surgeon was Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**]. On [**2116-6-2**],
he underwent an angiogram with coiling of the left internal
carotid artery aneurysm. He was neurologically sedated. His
vent drain was kept at 15 and he was given Ancef for drain
prophylaxis. Following the procedure, the patient opened
eyes to voice, followed some commands. He had left
hemiparesis. Pupils were reactive. He was neurologically
stable at that point. Endocrine was consulted regarding his
thyroidectomy. Cardiology saw the patient on [**2116-6-3**] at
neurosurgery's request regarding his elevated troponin level
and the electrocardiogram changes. At that time, as stated,
the electrocardiogram changes were likely representative of
cerebral T waves and are unlikely to be due to a myocardial
ischemia. The elevated troponin may represent demand
ischemia in the setting of an acute illness. The patient was
advised to follow-up with cardiology following discharge.
Endocrinology saw the patient on [**2116-6-3**] and agreed that he
should continue on his Levoxyl dose of 175 mg q. Day.
Otherwise, there were no interventions needed.
On [**2116-6-4**], the patient went into respiratory failure.
Anesthesia felt that it was prudent to intubate the patient
at this time and a follow-up magnetic resonance scan was
ordered. A follow-up magnetic resonance scan was ordered.
On [**2116-6-5**], the patient was reintubated for worsening
congestive heart failure. He now had developed a fever.
Plan was to start Impact with fiber and nasogastric tube.
For the next several weeks, the patient continued to spike
temperatures and blood cultures were ordered. Also,
cerebrospinal fluid cultures were ordered as well on [**2116-6-7**].
At that point, all cultures were negative. On [**2116-7-19**], the
patient was seen by ENT and the decision was made to put a
permanent tracheostomy. The patient was stable status post
tracheostomy. On the same day, [**6-19**], the patient was prepped
for percutaneous endoscopic gastrostomy. On [**6-19**], the
patient's vent drain was at 25 and clamped. His ICP ranged
from 6 to 11. Blood pressure was maintained at 160 to 180.
His tracheostomy was a number 7 Portex tracheostomy. He was
suctioned for a moderate amount of blood, with thick sputum.
Tracheostomy site was intact. Slight blood tinged drainage
oozing around the stoma was noted. Vent was changed from SIMV
to C-Pap with IPS. The patient was placed on Cefazolin one
gram q. Eight hours, in response to his constant temperature
spikes. Continue to follow blood cultures and cerebrospinal
fluid cultures. After several stable head CT and neurologic
stability, the patient's ventricular drain was discontinued
on [**6-23**]. To follow cerebrospinal fluid cultures, serial
lumbar punctures were performed. The patient's intracranial
hemorrhage remained stable through serial CAT scans. The
patient continued to spike fevers and had difficulty with his
tracheostomy and CTA showed bilateral large pulmonary
effusions. Infectious disease felt effusions were consistent
with congestive heart failure and fever.
The patient was followed throughout his course by infectious
disease and was placed on Vancomycin, Cefazolin and Flagyl.
They continued to follow cerebrospinal fluid cultures, sputum
cultures, blood cultures and urine cultures. On [**2116-6-27**],
culture showed nosocomial meningitis, Pseudomonas. The
patient was continued on Cefazolin and started on 4 mg
intrathecal Gentamycin q. 12 hours. Following cerebrospinal
fluid, white blood cell count dropped. Protein was dropping
and glucose was rising. On [**2116-6-28**], infectious disease said
that the patient still had pseudomonas meningitis and was
being treated with systemic Cefazolin and intrathecal
Gentamycin. He was to be continued on Vancomycin and Flagyl
for now. They advised continued surveillance of sputum,
blood cultures, urine cultures when febrile.
On [**2116-6-29**], the patient developed a fever still with
nosocomial meningitis. The patient had a complete fever work-
up at this time. Infectious disease had advised to add
Gentamycin systemically; watch the fever specifically with
Gentamycin intrathecally as inflammatory reaction could cause
this. They advised to continue Vancomycin and Flagyl
empirically and continue Ceptaz for pseudomonas and consider
repeat chest x-ray if still with fevers. For the next
several weeks, infectious disease recommendations were
followed, i.e. intrathecal Gentamycin, systemic Gentamycin,
Vancomycin and Flagyl. At this time, the patient's
neurologic status continues to improve.
On [**7-8**], on the advice of infectious disease, intrathecal
Gentamycin was discontinued, continue Ceptaz. Culture if
spikes. Okay to discontinue the Vancomycin. At this time,
the patient is being considered for ventriculoperitoneal
shunt. We will perform serial lumbar punctures to follow his
protein, glucose and culture cerebrospinal fluid. Infectious
disease agrees that if cultures are negative, it is okay to
proceed with ventriculoperitoneal shunt. On [**2116-7-10**], the
patient had a lumbar drain placed and the patient was prepped
and draped in the usual way, positioned and a lumbar drain
was placed without complications at L3, L4. Initial attempt
was complicated by venous bleeding. Instructions were to
drain 10 cc per hour, monitor ICP periodically with greater
than 20. Please call attending. The patient, at that time,
was neurologically stable. The patient continued to show
elevated white blood cells and PNMT's with high protein and
low glucose in his cerebrospinal fluid, suggestive of
recurrent nosocomial meningitis. The patient's final shunt
cerebrospinal fluid profile prior to discontinuing drain was
quite benign and initial lumbar puncture soon after, we
discontinued the drain. There was concern to the infectious
disease people that prior antibiotics were not adequately
distributed throughout cerebrospinal fluid. Infectious
disease felt that nosocomial meningitis regimen should be
reinstituted. This lumbar drain was placed so that we could
start IT Gentamycin regimen should be reinstituted. This
lumbar drain was placed so we could start IT Gentamycin via
lumbar drain. At this time, infectious disease felt that it
would be prudent to start Meropenem two grams q. 8 hours
intravenously and restart intrathecal Gentamycin via lumbar
drain, 4 mg q. 24 hours. Also felt to start intravenous
Gentamycin at the same dose, 180 mg q. 12 hours
intravenously. Neurosurgery would like to place a
ventriculoperitoneal shunt when all cultures are negative.
As of [**7-13**], all cultures have been negative. The patient's
examination continues to be the same but does not follow
commands. He opens his eyes to voice, localizes his upper
extremities and withdraws his lower extremities. Plan at
this time, on [**7-15**], is to place ventriculoperitoneal shunt
when cerebrospinal fluid protein is down and a renal consult
is requested due to rising BUN with creatinine levels.
Endocrine follow-up on [**2116-7-16**], patient still with nosocomial
meningitis. Endocrine would like to change Levoxyl to 150 mg
intravenous q. Day, check TFT's in one week. Will follow-up
with repeat TFT's are back next week.
On [**2116-7-17**], the patient was still with lumbar drain. Blood
pressure was below 160. Beta blocker to keep heart rate
around 60. Follow-up still following infectious disease
recommendations. Patient on subcutaneous heparin, Dilantin,
gastrointestinal prophylaxis. Neurologic examination remains
unchanged. Renal consult was obtained on [**2116-7-18**]. The
patient is a 77 year old male in mild acute renal failure,
developed slowly over the past ten days. Renal failure
starting 10 to 12 days after beginning high dose Gentamycin,
in the setting of Vancomycin and fevers consistent with
Gentamycin toxicity. This would fit with his high urine
sodium. Suggest hold ace inhibitors for now. Hold all
Lasix. Would give 250 cc of free water q. Six hours.
Vancomycin [**Hospital1 **] levels less than 15. Check daily level.
Intravenous Gentamycin was discontinued and would also
consider changing intrathecal Gentamycin to other [**Doctor Last Name 360**] as
even small systemic penetration will up his total Gentamycin
dose that accumulates and, if this is Gentamycin toxicity, it
can take days to weeks after discontinuing Gentamycin to see
resolution. Renal attending agreed with this and states that
he has been on intravenous Gentamycin for treatment of
meningitis for two courses. His creatinine started to rise
on [**7-8**] in the middle of the second cycle. Agreed that he
has ATN due to prerenal Gentamycin toxicity, renal function
can be very slow to recover with Gentamycin toxicity. Please
add on serum Gentamycin level to determine whether there is a
continuing effect from the IT therapy. Agree with free water
repletion given hypernatremia.
On [**7-20**], renal consult, Gentamycin toxicity leading to mild
acute renal failure, is improving slowly. Hypernatremia.
Please make euvolemic. Continue to follow renal consult. On
[**2116-7-22**], the patient had completed 14 days of Vancomycin and
intrathecal Gentamycin course on antibiotics to be
discontinued today. Antibiotics to be discontinued today.
Discontinue lumbar drain. Check lumbar puncture for
cerebrospinal fluid culture off antibiotics ideally for a few
days and then place ventriculoperitoneal shunt. [**2116-7-24**], the
patient is stable. Examination remained stable. The patient
opens eyes, does not follow commands, withdraws upper
extremities to pain, withdraws lower extremities to deep
stimulation. Lumbar puncture is to be performed daily. Over
the next several days, the patient's lumbar puncture
continued to show elevated intracranial pressures. Opening
pressure between 12 and 20. Cultures and laboratory studies
continued to be negative. Protein was decreasing. Glucose
was increasing over several days.
On [**2116-7-28**], the patient was pre-opped. The patient was
brought to the operating room for ventriculoperitoneal shunt
placement. The patient underwent an electrocardiogram.
Negative chest x-ray. Was made n.p.o. Signed a consent. His
laboratory studies were all within normal limits. On [**2116-7-30**],
the patient was taken to the operative suite for
ventriculoperitoneal shunt placement. Surgeon was Dr. [**Last Name (STitle) 1132**].
He was assisted by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. His preoperative diagnosis
was hydrocephalus. Postoperative diagnosis was the same.
Ventriculoperitoneal shunt was placed without complication
and he was sent to the Post Anesthesia Care Unit in stable
condition. On [**2116-8-3**], the patient was neurologically stable.
He was attentive and alert. All vital signs were stable.
Rehabilitation screening was completed. The patient could be
discharged on [**2116-9-4**] in stable condition.
DISCHARGE INSTRUCTIONS: The patient neurologic status should
be monitored closely. He is to follow-up with Dr. [**Last Name (STitle) 1132**] in
one month.
DISCHARGE MEDICATIONS: Levothyroxine sodium 275 mcg p.o. q.
Day.
Insulin subcutaneous sliding scale and fixed dose, per
insulin flow sheet.
Metoprolol 37.5 p.o. three times a day. Hold for systolic
blood pressure less than 110 or heart rate of less than 160.
Bisacodyl 10 mg p.r. h.s. prn.
Docusate sodium 100 mg p.o. twice a day.
Albuterol.
Ferrous sulfate 300 mg p.o. three times a day.
Heparin 5000 units subcutaneous q. 12 hours.
Miconazole powder 2 percent one application topically four
times a day prn.
Lansoprazole oral suspension 30 mg nasogastric q. Day.
The patient is discharged in stable condition to [**Hospital3 6373**] Center.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2116-8-3**] 20:17:43
T: [**2116-8-3**] 21:12:22
Job#: [**Job Number 12186**]
Admission Date: [**2116-6-1**] Discharge Date: [**2116-8-6**]
Date of Birth: [**2038-7-18**] Sex: M
Service:
ADDENDUM: Mr. [**Last Name (Titles) 12215**] discharge was postponed due to the
request of Dr. [**Last Name (STitle) 1132**] for him to have an IVC filter placed for
DVT prophylaxis. Mr. [**First Name (Titles) **] [**Last Name (Titles) 1834**] the IVC filter
placement on [**2116-8-5**] without any difficulties. He also had
a Passy-Muir valve placed. Once that was placed, he has
begun to speak. There were no other changes in his medical
care.
RECOMMENDED FOLLOW-UP: He should have staples removed on
[**2116-8-9**]. He should follow-up with Dr. [**Last Name (STitle) 1132**] in the next 3-4
weeks. They should call [**Telephone/Fax (1) 2992**]. Mrs. [**Last Name (STitle) **] has been
given this information.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2116-8-6**] 13:32:56
T: [**2116-8-6**] 14:12:27
Job#: [**Job Number **]
Admission Date: [**2116-6-1**] Discharge Date: [**2116-8-6**]
Date of Birth: [**2038-7-18**] Sex: M
Service:
ADDENDUM: On [**2116-8-3**], the patient's all vital signs were
stable. The patient was attentive and moved all 4
extremities spontaneously. His incision from shunt placement
was clean, dry, and intact. The patient was to be screened
for rehab at this time. On [**2116-8-5**], the patient had an IVC
filter placed for prophylaxis of deep venous thrombosis. The
procedure went without complications. Postoperatively, the
patient was in stable condition. His vital signs were
temperature was 96.6, blood pressure 132/70, heart rate was
61, and his respiratory rate was 16. The patient was without
complaint. He was mouthing the words that he is okay. The
patient is alert and oriented to name and place. He
recognized the daughter and his wife. [**Name (NI) **] opens his eyes and
responds by mouthing words. He is following some commands.
He grips and wiggling toes. His strength in his grips is 2
out of 5. The insertion site in his right groin is clean,
dry, and intact. The patient is to go to rehab on [**2116-8-6**].
DISCHARGE INSTRUCTIONS: Continue frequent neurological
checks. Continue to monitor kidney function for elevated BUN
and creatinine levels. Check TSH and free T4 in 1 week. If
TSH is not less than 26, he should increase Synthroid.
FINAL DIAGNOSES: Status post right ICA and MCA aneurysm
coiling.
Status post VP shunt placement.
Status post inferior vena cava filter.
RECOMMENDED FOLLOWUP: Staples from his shunt placement
should be removed 10 days post surgery on [**2116-8-9**] and he
should followup with Dr. [**Last Name (STitle) 1132**] in 1 month.
SURGICAL PROCEDURES: His major surgical procedures were
right ICA and MCA aneurysm coiling, open tracheostomy, VP
shunt placement, and an IVC filter placement.
CONDITION ON DISCHARGE: He is neurologically stable at this
time.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg capsule delayed release 1 capsule p.o.
q.d.
2. Miconazole nitrate powder 1 application 4 times a day as
needed.
3. Heparin 5000 units per mL solution 1 injection q. 12h.
4. Ferrous sulfate 300 mg and 500 mL liquid 1 p.o. t.i.d.
5. Docusate sodium 150 mg in 15 mL liquid 1 to 2 p.o. b.i.d.
6. Bisacodyl 10 mg suppository 1 suppository rectal at
bedtime as needed.
7. Metoprolol tartrate 25 mg tablet 1.5 tablets p.o. t.i.d.
8. Therapeutic multivitamin liquid 5 mL p.o. q.d.
9. Levothyroxine sodium 137 mcg tablet 2 tablets p.o. q.d.
10. Insulin NPH Human, 100 unit per mL suspension 1 unit
subcutaneous twice a day, the patient currently on sliding
scale dosing as well as fixed dosing of 10 units of NPH at
breakfast and 10 units at dinner.
CONDITION ON DISCHARGE: The patient's discharge condition is
neurologically stable.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] m.d. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2116-8-5**] 15:09:11
T: [**2116-8-5**] 16:21:17
Job#: [**Job Number **]
|
[
"599.0",
"428.0",
"331.4",
"320.82",
"584.5",
"518.82",
"430",
"276.0",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.29",
"43.11",
"38.93",
"96.04",
"38.7",
"88.41",
"02.2",
"03.31",
"02.34",
"96.72",
"96.6",
"39.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6607, 6685
|
24027, 24815
|
7592, 7649
|
8531, 19884
|
23236, 23446
|
7503, 7566
|
23464, 23936
|
6501, 6585
|
7672, 8513
|
6714, 7167
|
7190, 7479
|
1193, 1554
|
24840, 25149
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,107
| 118,137
|
7169
|
Discharge summary
|
report
|
Admission Date: [**2148-3-22**] Discharge Date: [**2148-3-27**]
Date of Birth: Sex:
Service:
HISTORY: Ms. [**Known lastname **] was a 66-year-old female who
underwent multiple surgeries at ____________ Hospital, and
was transferred to this facility for further management. She
was taken to the operating room on [**2-20**], where she
underwent MVR, AVR, and a CABG. She had a difficult
postoperative course complicated by pressure requirement, C.
difficile colitis, worsening renal failure. She underwent a
CT scan of the abdomen on [**3-10**], which demonstrated free
air and free fluid. She was taken to the operating room.
She underwent a total abdominal colectomy, colostomy. She
had multiple infectious complications and was transferred to
this facility on [**2148-3-23**] for further management. Upon
arrival to this institution, she was critically ill with
multi-system organ failure. She had a markedly elevated
white count at approximately 40,000 with evidence of ongoing
sepsis and multi-system organ failure. She was jaundice with
a total bilirubin in the 7 range, acidotic, elevated lactate.
She had multiple cultures performed with _____________ in her
sputum and [**Female First Name (un) **] albicans in her pleural fluid. Multiple
consultations were performed. Cardiology was consulted,
cardiac surgery, thoracic surgery, and infectious disease.
Over the course of her very short hospitalization, she
continued to require pressures, and deteriorated. We could
not find an ongoing source of sepsis, and on [**2148-3-27**] she
expired.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2148-9-10**] 14:35:30
T: [**2148-9-10**] 16:46:44
Job#: [**Job Number 26631**]
|
[
"V45.81",
"V44.2",
"518.0",
"V45.01",
"486",
"518.5",
"112.5",
"785.52",
"E878.3",
"584.9",
"V45.72",
"V43.3",
"112.4",
"530.81",
"585.9",
"995.92",
"403.90",
"414.01",
"511.9",
"998.12",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,805
| 196,011
|
33267
|
Discharge summary
|
report
|
Admission Date: [**2154-7-2**] Discharge Date: [**2154-7-12**]
Date of Birth: [**2077-1-31**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
77 year old patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77244**] and Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] with atrial fibrillation, referred for pulmonary vein
isolation procedure.
Major Surgical or Invasive Procedure:
Atrial Fibrillation Ablation
Cardioversion
Placement of right IJ Line
Intubation
History of Present Illness:
This is a 77 year old gentleman with CAD s/p PCI to the LAD in
[**2141**],
hypertension and dyslipidemia has been in persistant atrial
fibrillation over the past year and a half despite multiple
cardioversions and a pulmonary vein isolation procedure [**2153-12-23**]
in [**Location (un) **], NY.(4 pulmonary veins were isolated). He converted
back to atrial fibrillation the following day and has remained
in
it since. He has not been cardioverted since his PVI. He was
previously treated with Sotalol but was changed to Nadolol and
Digoxin following his last PVI. He is s/p cardiac
catheterization
in [**Location (un) **] in [**2154-4-4**], which reportedly did not reveal any
obstructive CAD or pulmonary vein stenosis. The patient is
symptomatic with severe fatigue, shortness of breath and lower
extremity edema.
Past Medical History:
Persistant atrial fibrillation x 1.5 years s/p CV and PVI
CAD s/p PCI to the LAD in [**2141**]
Hypertension
Dyslipidemia
Reactive airway disease
Hernia repair
Pilonidal cyst
Social History:
Retired dentist. Married and lives with his wife.
[**Name (NI) **] one adult child.
Family History:
Father died of an MI at age 55
Physical Exam:
Discharge Physical Exam:
T: 98, BP 93/57, HR: 56, RR: 18, O2: 95% on RA.
GEN: NAD
SKIN: Eccymosis on UE b/l.
CV: S1+, S2+, RRR, No murmurs.
PULM: Rhales at bases b/l
GI: BS+, Soft, NT/ND
EXT: 2+ edema to knees.
Neuro: AAOx3
Pertinent Results:
CBC:
[**2154-7-2**] WBC-6.1 RBC-4.51* Hgb-14.3 Hct-41.9 Plt Ct-172
[**2154-7-12**] WBC-6.1 RBC-3.69* Hgb-11.8* Hct-34.3* Plt Ct-242
.
Coags:
[**2154-7-12**] PT-22.4* PTT-33.2 INR(PT)-2.1*
.
Chemistry:
[**2154-7-2**] Glucose-89 UreaN-25* Creat-1.0 Na-146* K-4.1 Cl-112*
HCO3-24 AnGap-14
[**2154-7-12**] Glucose-89 UreaN-24* Creat-1.5* Na-138 K-4.0 Cl-105
HCO3-26 AnGap-11
[**2154-7-12**] Calcium-8.2* Phos-2.8 Mg-2.2
.
LFTs:
[**2154-7-10**] ALT-38 AST-50* AlkPhos-72 TotBili-0.7
.
CE:
[**2154-7-4**] CK-MB-5 cTropnT-0.46*
[**2154-7-3**] CK-MB-6 cTropnT-0.62*
[**2154-7-3**] CK-MB-7 cTropnT-0.59*
.
Iron studies:
[**2154-7-6**] calTIBC-164* Hapto-170 Ferritn-421* TRF-126*
.
[**2154-7-11**]: ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is 0-5
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size. Overall left ventricular systolic function
is low normal (LVEF 50-55%). The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is mild pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
.
Compared with the prior study (images reviewed) of [**2154-7-8**], the
left ventricle is better visualized with improved function. The
right ventricle remains similar with mild estimated pulmonary
artery systolic hypertension.
Brief Hospital Course:
Patient was undergoing pulmonary vein isolation which was
complicated by a cardiac tamponade. His blood pressure dropped
and he persisted in A-FIB. He underwent one DCCV but his blood
pressure continued to drop. He had been electively intubated
for the procedure. A code Blue was called. He went into a PEA
and CPR was started. A pericardial drain was placed emergently
which drained 750cc of serosanguinous fluid. He was resuscitated
although required pressors to maintain his blood pressure. After
the initial resuscitation the patient reverted to normal sinus
rhythm.
.
The patient was transfered to the CCU. He did well and was able
to be extubated two days later. His blood pressure slowly
normalized and he was able to be weaned off of pressors.
Unfortunately he went back into A-FIB on [**2154-7-4**]. He was started
on a heparin drip to bridge him to coumadin and also started on
amiodarone. His pericardial drain stopped draining fluid ans
was pulled. He required 1 unit of blood durring this time. He
continued to do well and the decision was made to attempt a
cardioversion. He was succesfully cardioverted on [**2154-7-9**] and
transfered to the floor. He remained in normal sinus rhythm
upon disharge. A final echo showed an LVEF of 50-55% and no
pericardial effusion.
Medications on Admission:
Mvi daily
Osteobiflex daily
Claritin 10mg daily
Flonase nasal spray PRN
Duoneb 1 puff daily at night
Foradil aerolizer 12mcg capsule with inhalation [**Hospital1 **]
Omeprazole 20mg daily
Asmanex twisthaler 1puff [**Hospital1 **]
Albuterol inhaler PRN
Niacin 1000mg daily
Potassium chloride 20meq [**Hospital1 **]
Lasix 40mg daily
Zocor 20mg daily
Coumadin 4mg daily-last dose Thurs [**6-27**]
Aspirin 81mg every other day
Corgard 40mg [**Hospital1 **]
Lanoxin 0.125mg daily
Synthroid 0.125mg daily
Discharge Medications:
1. Levothyroxine 125 mcg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
2. Atrovent HFA 17 mcg/Actuation Aerosol Sig: [**12-5**] Inhalation
four times a day.
3. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-5**] Inhalation four
times a day as needed for shortness of breath or wheezing.
4. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation twice a day.
5. Claritin 10 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO once a day.
6. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr Breath
Activated Sig: One (1) Inhalation three times a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Multi-Day [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO once a day.
9. Vitamin C 500 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO once a day.
10. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
11. Niaspan 1,000 mg [**Month/Day (2) 8426**] Sustained Release Sig: One (1)
[**Month/Day (2) 8426**] Sustained Release PO at bedtime.
12. Zocor 40 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO once a day.
13. Acetaminophen 325 mg [**Month/Day (2) 8426**] Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Furosemide 40 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY
(Daily).
15. Aspirin 81 mg [**Month/Day (2) 8426**], Chewable Sig: One (1) [**Month/Day (2) 8426**], Chewable
PO once a day.
16. Coumadin 4 mg [**Month/Day (2) 8426**] Sig: dose per doctor [**First Name (Titles) 8426**] [**Last Name (Titles) **] at
bedtime: To be resumed after coumadin level (INR) is less than
2. .
17. Outpatient Lab Work
Please have your INR, BUN, Creatinine, K and Mag checked on
[**7-15**] and call results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 77245**] and
Dr. [**Last Name (STitle) 349**] [**Telephone/Fax (1) 77246**]
18. Amiodarone 200 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO once a day.
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*1*
19. Amiodarone 200 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO once a day.
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*5*
20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
21. Magnesium Oxide 400 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO twice a
day.
Disp:*60 [**Telephone/Fax (1) 8426**](s)* Refills:*1*
22. Magnesium Oxide 400 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO twice a
day.
Disp:*60 [**Telephone/Fax (1) 8426**](s)* Refills:*3*
23. Metoprolol Succinate 25 mg [**Telephone/Fax (1) 8426**] Sustained Release 24 hr
Sig: One (1) [**Telephone/Fax (1) 8426**] Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 [**Telephone/Fax (1) 8426**] Sustained Release 24 hr(s)* Refills:*1*
24. Metoprolol Succinate 25 mg [**Telephone/Fax (1) 8426**] Sustained Release 24 hr
Sig: One (1) [**Telephone/Fax (1) 8426**] Sustained Release 24 hr PO once a day.
Disp:*30 [**Telephone/Fax (1) 8426**] Sustained Release 24 hr(s)* Refills:*5*
25. Amiodarone 200 mg [**Telephone/Fax (1) 8426**] Sig: Two (2) [**Telephone/Fax (1) 8426**] PO once a day
for 4 days.
Disp:*8 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
26. Warfarin 3 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO once a day:
Please take Friday, Saturday, Sunday, then check INR on Monday.
Dr. [**Last Name (STitle) **] will decide your dose on Monday. .
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Coronary Artery Disease
Pericardial effusion with tamponade
Discharge Condition:
Stable
Discharge Instructions:
You had an atrial fibrillation ablation that was complicated by
a collection of fluid around your heart requiring a ventilator
and medications to keep your blood pressure up. You had a tap to
draw out the fluid around your heart and the last ECHO showed no
fluid. You continued to have atrial fibrillation and were
started on amiodarone and cardioverted again on [**2154-7-9**]. Since
that time, you have been in a normal sinus rhythm. You will
continue to take the amiodarone at 400mg (2 pills) daily for 4
days until [**2154-7-17**], then decrease to 200mg daily (1 pill).
Please follow-up with your cardiologist and primary care doctor
as scheduled.
.
You should start taking your warfarin again today, check your
INR on Monday [**7-15**].
New Medications:
Amiodarone: keeps you in a normal heart rhythm
Metoprolol Succinate: to keep you heart rate low
Magnesium Oxide: to keep your magnesium level up
.
Do not take the following medications anymore:
Corgard
Digitek
Vardenafil (please talk to your cardiologist about continuing
this medication on amiodarone)
Please make sure to have an electro-cardiogram when you next see
your cardiologist.
You also need to have pulmonary function tests performed
annually while on Amiodarone. Please talk to Dr. [**Last Name (STitle) **]
about setting up baseline pulmonary function tests.
Your magnesium and potassium were low and you required
supplements daily. Please continue to take these after
discharge.
Followup Instructions:
Primary care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**], MD Phone: [**Telephone/Fax (1) 77246**] Fax:
[**Telephone/Fax (1) 77247**] Date/Time: [**2154-8-6**] at 10:45am
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 77245**] Date/time;
[**2154-7-26**] at 11:15 am.
Pulmonary Function Testing
ECG
|
[
"414.01",
"427.31",
"997.1",
"785.51",
"427.5",
"423.9",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"99.60",
"88.72",
"99.61",
"96.04",
"37.0",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9353, 9359
|
3796, 5088
|
509, 592
|
9483, 9492
|
2047, 3773
|
10996, 11405
|
1754, 1788
|
5639, 9330
|
9380, 9462
|
5114, 5616
|
9516, 10973
|
1803, 1803
|
234, 471
|
620, 1439
|
1461, 1637
|
1653, 1738
|
1828, 2028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,931
| 139,779
|
7049
|
Discharge summary
|
report
|
Admission Date: [**2130-6-7**] Discharge Date: [**2130-6-14**]
Date of Birth: [**2060-4-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Patient is a 70 year old male with cholecystectomy and hepatitis
C complicated by advanced stage fibrosis and cirrhosis
nonresponsive to interferon and ribavirin. He presented to OSH
five days ago with upper abdominal pain associated with
vomiting. He does not report fever or chills. Labs were
significant for elevated T. bili to 6. CT abdomen showed no
acute intrabdominal process.
.
He reports feeing more itchy and worsening of his abdominal pain
with nausea. Labs yesterday at his PCP's office showed worsening
direct bilirubenemia to 8.7 (T.bili of 10.8). He was instructed
to come to [**Hospital1 18**] ED.
.
In the ED, initial VS were 98.0 59 131/69 16 99%. Ordered RUQ
ultrasound showed known cirrhosis and 4 mm nondilated CBD. He
was given IV zosysn with concern for cholangitis and admitted to
liver service for further evaluation and management.
.
On the floor, he reports no other complaints.
Past Medical History:
Hepatitis C cirrhosis
Atrial fibrillation
Hypertension
Type 2 DM
Social History:
Quit smoking > 10 years ago. No alcohol use. Married with good
family support
Family History:
NC
Physical Exam:
Admission Physical Exam:
VS: 96.9 130/70 103 16 97%RA
GENERAL: Male in mild distress
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft and nondistended. TTP at RUQ with guarding. No
rebound tenderness noted
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
Discharge Physical:
General: NAD
HEENT: anicteric sclerae
Abdomen: soft, nontender, nondistended
otherwise, exam unchanged
Pertinent Results:
[**2130-6-7**] 05:05PM BLOOD WBC-7.5 RBC-5.06 Hgb-16.1 Hct-47.6 MCV-94
MCH-31.7 MCHC-33.7 RDW-14.2 Plt Ct-149*
[**2130-6-8**] 05:25AM BLOOD WBC-6.5 RBC-4.90 Hgb-15.3 Hct-46.6 MCV-95
MCH-31.2 MCHC-32.8 RDW-14.1 Plt Ct-124*
[**2130-6-8**] 09:10AM BLOOD WBC-11.3*# RBC-4.94 Hgb-15.6 Hct-46.4
MCV-94 MCH-31.5 MCHC-33.5 RDW-14.1 Plt Ct-175
[**2130-6-7**] 05:05PM BLOOD Neuts-75* Bands-0 Lymphs-18 Monos-6 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2130-6-8**] 05:25AM BLOOD Neuts-74.8* Lymphs-17.8* Monos-4.9
Eos-1.4 Baso-1.1
[**2130-6-7**] 05:05PM BLOOD PT-33.1* PTT-41.2* INR(PT)-3.3*
[**2130-6-8**] 05:25AM BLOOD PT-30.7* PTT-41.3* INR(PT)-3.0*
[**2130-6-8**] 04:09PM BLOOD PT-19.2* PTT-33.5 INR(PT)-1.7*
[**2130-6-7**] 05:05PM BLOOD Glucose-177* UreaN-35* Creat-1.2 Na-138
K-4.2 Cl-105 HCO3-22 AnGap-15
[**2130-6-8**] 05:25AM BLOOD Glucose-217* UreaN-32* Creat-1.1 Na-133
K-4.5 Cl-103 HCO3-19* AnGap-16
[**2130-6-7**] 05:05PM BLOOD ALT-81* AST-80* AlkPhos-313*
TotBili-11.1* DirBili-9.2* IndBili-1.9
[**2130-6-8**] 05:25AM BLOOD ALT-70* AST-72* LD(LDH)-169 AlkPhos-287*
TotBili-10.7* DirBili-9.0* IndBili-1.7
[**2130-6-7**] 05:05PM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.1 Mg-2.4
[**2130-6-8**] 05:25AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.3
[**2130-6-7**] 05:05PM BLOOD Osmolal-296
[**2130-6-7**] 05:11PM BLOOD Lactate-1.3
.
[**2130-6-8**] BLOOD CULTURE Blood Culture,
Routine-PENDING [**2130-6-7**] BLOOD CULTURE Blood
Culture, Routine-PENDING [**2130-6-7**] BLOOD CULTURE
Blood Culture, Routine-PENDING
.
Abd U/S:
IMPRESSION:
1. Heterogeneous and coarse liver compatible with cirrhosis with
splenomegaly suggestive of portal hypertension. No focal lesion.
2. Status post cholecystectomy without intra- or extra-hepatic
biliary ductal dilatation.
.
Brief Hospital Course:
Primary reason for hospitalization:
Patient is a 70 year old male s/p cholecystectomy and with HCV
cirrhosis who presented to the hospital with a 5 day history of
abdominal pain, nausea, low grade temperatures at home,
jaundice, and direct bilirubinemia. He was found to have
cholangitis that was complicated by atrial fibrillation with
rapid ventricular response.
.
Active Diagnoses:
1. Cholangitis: Given triad of fever, right upper quadrant pain,
and jaundice, patient's presentation was very concerning for
cholangitis. RUQ US did not show any pathology but common bile
duct dilatation can be missed on RUQ US. ERCP failed to show
bile duct stone or sludge, but demonstrated a widely patent
sphincter of Oddi. A biliary stent was placed, and patient was
started on Ciprofloxacin and Flagyll. With this therapy,
patient's bilirubin decreased, and fevers and abdominal pain
resolved. He was discharged with instruction to complete a
two-week course.
.
2. Atrial fibrillation: Patient has history of paroxysmal afib
with RVR and during the ERCP, patient's rhythm switched to afib
and he had RVR to 200's. He went to the ICU and went back to the
floor where his heart rate still ran in the 140's on full dose
metoprolol. Diltiazem was added on to patient's medications and
heart rate was controlled to below 100. Patient's INR became
supratherapeutic on his home dose of warfarin in the setting of
antibiotic use, so his dose was decreased and then held while
awaiting recovery of his INR to therapeutic range.
.
Chronic Diagnoses:
1. Hypertension: Home Lisinopril was held due to concern for
cholangitis. BPs were in good range during admission.
.
2. Type 2 DM: Patient was maintained on insulin sliding scale
coverage
.
3. Dementia: Home Mamenda was initially held, but then
restarted. Pt was continued on home Citalopram.
.
Transitional Care:
Patient was advised that he not go on a scheduled cruise given
recent changes to medications and the need to have access to
medical care if needed.
Patient's home coumadin dosing was held given supratherapeutic
INR. He was instructed to have INR measured on Friday [**6-16**] and
given a prescription for lab draw, and have coumadin re-dosed
based on INR frequently while on antibiotics by speaking to his
primary care doctor who manages his coumadin.
Patient was instructed to follow up with his gastroenterologist,
PCP, [**Name10 (NameIs) 2085**], as well as to make sure that he is on the
right dose of coumadin based on results of lab draw.
Patient was instructed to return for removal of biliary stent.
Appointment was booked.
Medications on Admission:
Cilostazol 100 mg po BID
Citalopram 20 mg po qdaily
Lantus 50 units qam
Humalog sliding scale (usually 4-6 units at night)
Lisinopril 5 mg po qdaily
Namenda 5mg qpm
Metoprolol 100 mg po BID
Omeprazole 40 mg po qdaily
Warfarin 1mg daily on Tuesday, Friday, Sunday; 2mg daily all
other days.
Discharge Medications:
1. cilostazol 100 mg [**Name10 (NameIs) 8426**] [**Name10 (NameIs) **]: One (1) [**Name10 (NameIs) 8426**] PO bid ().
2. citalopram 20 mg [**Name10 (NameIs) 8426**] [**Name10 (NameIs) **]: One (1) [**Name10 (NameIs) 8426**] PO DAILY (Daily).
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Name10 (NameIs) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. metoprolol tartrate 100 mg [**Name10 (NameIs) 8426**] [**Name10 (NameIs) **]: One (1) [**Name10 (NameIs) 8426**] PO
twice a day.
5. lisinopril 5 mg [**Name10 (NameIs) 8426**] [**Name10 (NameIs) **]: One (1) [**Name10 (NameIs) 8426**] PO DAILY (Daily).
6. Namenda 10 mg [**Name10 (NameIs) 8426**] [**Name10 (NameIs) **]: One (1) [**Name10 (NameIs) 8426**] PO twice a day.
7. warfarin 1 mg [**Name10 (NameIs) 8426**] [**Name10 (NameIs) **]: 1.5 Tablets PO Once Daily at 4 PM:
please do not take this medicine until you have your labs
checked and told to restart by your physician. [**Name Initial (NameIs) 8426**](s)
8. diltiazem HCl 300 mg Capsule, Extended Release [**Name Initial (NameIs) **]: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
9. insulin lispro 100 unit/mL Solution [**Name Initial (NameIs) **]: use the sliding
scale Subcutaneous qachs: please use your sliding scale as you
did previously.
10. Lantus 100 unit/mL Solution [**Name Initial (NameIs) **]: Fifty (50) units
Subcutaneous once a day.
11. ciprofloxacin 500 mg [**Name Initial (NameIs) 8426**] [**Name Initial (NameIs) **]: One (1) [**Name Initial (NameIs) 8426**] PO Q12H
(every 12 hours) for 7 days.
Disp:*14 [**Name Initial (NameIs) 8426**](s)* Refills:*0*
12. metronidazole 500 mg [**Name Initial (NameIs) 8426**] [**Name Initial (NameIs) **]: One (1) [**Name Initial (NameIs) 8426**] PO Q8H
(every 8 hours) for 7 days.
Disp:*21 [**Name Initial (NameIs) 8426**](s)* Refills:*0*
13. Outpatient Lab Work
Please have INR checked on Friday [**2130-6-16**] and have results
communicated to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4343**],[**First Name3 (LF) **] A.
Phone: [**Telephone/Fax (1) 26330**]
Fax: [**Telephone/Fax (1) 26331**]
14. Namenda 5 mg [**Telephone/Fax (1) 8426**] [**Telephone/Fax (1) **]: One (1) [**Telephone/Fax (1) 8426**] PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1) Cholangitis
2) Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 26332**],
You were admitted to our hospital with cholangitis, you had a
stent placed in your liver for this. Your liver tests have
improved. While here, your atrial fibrillation caused you to
have increased heart rate. We have started you on a medicine to
control your heart rate and it improved. You will need to follow
up with your primary care doctor, your cardiologist as well as
have your INR checked this Friday, [**6-16**], to make sure that
your coumadin level is adequate. You will also have to come
back and have your stent removed.
We also discussed with you the risks of going to the cruise, and
importance of keeping your appointments and blood draws. We feel
strongly that you should avoid travel at this time, and
concentrate on getting your health under control.
The following changes were made to your medications:
1) START Diltiazem
2) START CIPROFLOXACIN 500mg [**Month (only) **] twice daily for 7 days
3) START Metronidazole 500mg [**Month (only) **] three times per day for 7
days
Followup Instructions:
Department: ENDO SUITES
When: THURSDAY [**2130-7-20**] at 9:00 AM
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2130-7-20**] at 9:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: LIVER CENTER
When: FRIDAY [**2130-8-18**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 4343**],[**First Name3 (LF) **] A.
Location: [**Location (un) **] PRIMARY CARE
Address: [**Street Address(2) 26333**] [**Apartment Address(1) 26334**], [**Location (un) **],[**Numeric Identifier 26335**]
Phone: [**Telephone/Fax (1) 26330**]
When: Tuesday, [**2129-6-20**]:45AM
Name: [**Last Name (LF) 5686**], [**Name8 (MD) **] MD./ Cardiology
Address: [**Street Address(2) 26336**], [**Location (un) 1468**],MA
Phone: [**Telephone/Fax (1) 11554**]
When: Wednesday, [**6-28**], 1:15PM
|
[
"V45.89",
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"799.02",
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icd9cm
|
[
[
[]
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[
"51.87"
] |
icd9pcs
|
[
[
[]
]
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9159, 9165
|
3925, 4293
|
317, 323
|
9247, 9247
|
2157, 3902
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,659
| 119,066
|
44818
|
Discharge summary
|
report
|
Admission Date: [**2201-7-4**] Discharge Date: [**2201-7-9**]
Date of Birth: [**2122-7-15**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Vancomycin
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 78M with CHF (EF 20%), chronic renal insufficiency
(baseline Cr 2.2-2.6), Atrial Fibrillation, who presents with
increasing edema. According to patient, he was in his usual
state of health until 3 weeks ago, when he began experiencing an
increase in LE edema. Reports gradual increase in weight, with
most recent report of 4lb increase in weight over the last 2
days. [**First Name3 (LF) 4273**] excessive salt intake, no recent infection, no
chest pain. [**First Name3 (LF) 4273**] cough, SOB, orthopnea, palpitations,
dizziness or lightheadedness. Patient came to the Emergency
Department given weight change and increasing edema.
Past Medical History:
1. CKD [**2-19**] HTN, cardiorenal syndrome
2. CAD s/p CABG [**2185**] with stenting in [**2198**] and [**2199**]
3. CHF - Ischemic cardiomyopathy with severe LV systolic
dysfunction
with LVEF of 20%
4. VT status post ICD with biventricular capability
5. Atrial Fibrillation, rate controlled, on coumadin
6. Anemia
7. BPH
8. Hypothyroidism [**2-19**] amio
9. Amio induced pulm toxicity
10. H/O MRSE bacteremia, [**12-22**], unclear source
11. s/p CCY?
Social History:
Lives with wife in [**Name (NI) 583**] in an apartment building. Retired
engineer. One son who lives in [**Name (NI) 1468**] and is involved with his
father's care.
Tob: quit 30 years ago; before that 25 year history at 1.5 ppd
EtOH: occasional
IVDA:none
Family History:
Mother with MI, died at 64; Father died at 86 in [**Country 532**] of "old
age"; Son with no medical problems
Physical Exam:
VITALS: T 96.6, BP 134/63, HR 74, RR 20, O2sat 94% RA
GEN: chronically ill-appearing, NAD
HEENT: PERRL, EOMI, Sclera anicteric, dry MM, no OP lesions
NECK: Large - JVP not observed. No carotid bruits
PULM: Lungs are clear to auscultation bilaterally. no
crackles/wheezes/rhonchi
CV: irregularly irregular, distant heart sounds, S1, S2,
murmurs/rubs/gallops could not be appreciated
ABD: SNT, ND, NABS, no HSM, 4+ presacral edema
EXT: 4+ pitting edema to thighs, 1+ DP pulses
NEURO: alert and oriented x 3
Pertinent Results:
[**2201-7-4**] 10:00PM POTASSIUM-5.7*
[**2201-7-4**] 10:00PM CK(CPK)-367*
[**2201-7-4**] 10:00PM CK-MB-12* MB INDX-3.3 cTropnT-0.20*
[**2201-7-4**] 02:27PM K+-5.7*
[**2201-7-4**] 11:45AM GLUCOSE-74 UREA N-78* CREAT-3.6* SODIUM-138
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-22 ANION GAP-19
[**2201-7-4**] 11:45AM ALT(SGPT)-109* AST(SGOT)-173* CK(CPK)-489*
ALK PHOS-761* AMYLASE-93 TOT BILI-1.9*
[**2201-7-4**] 11:45AM LIPASE-33
[**2201-7-4**] 11:45AM CK-MB-14* MB INDX-2.9
[**2201-7-4**] 11:45AM PT-30.7* PTT-44.4* INR(PT)-3.2*
[**2201-7-4**] 10:00AM WBC-9.3 RBC-4.00* HGB-12.7* HCT-38.3* MCV-96
MCH-31.8 MCHC-33.3 RDW-18.5*
[**2201-7-4**] 10:00AM NEUTS-93* BANDS-0 LYMPHS-1* MONOS-5 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2201-7-4**] 10:00AM PLT SMR-NORMAL PLT COUNT-188#
[**2201-7-4**] 10:00AM PT-30.1* PTT-41.6* INR(PT)-3.2*
Brief Hospital Course:
This is a 78 year old gentleman with class IV CHF with an EF
20%, AF, cardiorenal syndrome, CRI, hypothyroidism, presenting
with severe CHF decompensation refractory to standard diuretic
therapies. He was transferred to the CCU after developing
hypotension with associated mental status change after attempted
diuresis with IV lasix drip along with nesiritide. In order to
treat the hypotension, consideration must be given to his poor
heart function which, in and of itself, likely has large
contribution to the hypotensive picture. The patient was
started on lasix drip with dopamine for inotropic support. His
hemodynamic status remained tenuous and his urine output was
only marginally satisfactory. The following morning the patient
went into atrial fibrillation and became hypotensive.
Cardioversion was not successful. Levophed was started for
blood pressure support, dopamine was weaned. Chemical
cardioversion and rate control was successfully achieved with
amiodarone. The patients hemodynamic status improved. The
following morning, however, the patient again became hypotensive
with increasing oxygen requirement and declining urinary output.
Mental status unchanged. Vasopressin was added for blood
pressure support.
Given these events, Dr. [**First Name (STitle) 437**] called a family meeting to explain
that the prognosis, unfortunately, was extremely poor. The
family elected to make the patient comfort measure only.
Pressors were weaned off and all medicines not realted to
comfort were discontinued. The patient expired the afternoon of
[**2201-7-9**]. His family was at the bedside.
Medications on Admission:
Aspirin 325mg once daily
Plavix 75mg once daily
Metoprolol XL 100mg once daily
Chlorothiazide 250 mg IV BID
Nesiritide 0.02mcg/kg/min gtt
Lasix gtt 10mg/hour
Levothyroxine 200 mcg once daily
Doxycycline Hyclate 100 mg PO Q12H
Protonix
Iron
Folic Acid
Colace/Senna
Acetaminophen prn
Discharge Medications:
Not applicable
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary
1. Decompensated Heart Failure
2. Acute on Chronic Renal Failure
3. Hypothyroidism
Secondary
1. HTN,
2. Cardiorenal syndrome
3. CAD s/p CABG [**2185**] with stenting in [**2198**] and [**2199**]
4. CHF - Ischemic cardiomyopathy with severe LV systolic
dysfunction, last LVEF 20%
5. VT status post ICD with biventricular capability
6. Atrial Fibrillation, rate controlled, on coumadin
7. Anemia, multifactorial including chronic kidney disease
8. BPH
9. Hypothyroidism [**2-19**] amio
10. Amiodarone Toxicity: Pulmonary and Thyroid (Hypothyroidism)
11. H/O MRSE bacteremia, [**12-22**], unclear source
12. s/p CCY
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
|
[
"428.20",
"276.7",
"414.00",
"V53.32",
"584.9",
"414.8",
"V45.81",
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"404.93",
"785.51"
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icd9cm
|
[
[
[]
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[
"00.13",
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icd9pcs
|
[
[
[]
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5253, 5268
|
3264, 4881
|
288, 295
|
5934, 5943
|
2387, 3241
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6006, 6023
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1735, 1846
|
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243, 250
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323, 970
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992, 1446
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1462, 1719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,624
| 172,139
|
43932+58668
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-12-15**] Discharge Date: [**2132-12-19**]
Date of Birth: [**2063-10-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Tetracyclines / Erythromycin Base /
Ciprofloxacin
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Central line
PICC line
History of Present Illness:
Mr. [**First Name4 (NamePattern1) **] [**Known lastname 13469**] is a 69yo gentleman known to the hospital
medicine and ICU team who was recently admitted with weakness
and aspiration and who now presents with hypotension.
Mr. [**Known lastname 13469**] was admitted [**Date range (1) 63728**] with c/o weakness. During
that admission, he briefly stayed in the ICU overnight for
concern of pneumonia, which resolved quickly and was therefore
felt to represent aspiration pneumonitis. A Chest CT done
immediately after his ICU stay documented resolution of his left
lower lobe consolidation but persistent atelectasis and
bronchiectasis consistent with recurrent aspiration.
He was discharged on [**12-14**] but states that he was not feeling
well at the time he left the hospital. He went to his shelter
at [**Hospital1 **] and noted that he was feeling weak and lightheaded.
He reports having a poor appetite but eating yoghurt and taking
in fluids nonetheless. He states that as part of his intake at
[**Hospital1 **], his blood pressure was checked and was found to be
"very low." He was therefore sent to the ED for evaluation.
In the ED, initial VS were: 97.0 50/37 58 16 99% RA.
He was alert and oriented and reported chest pain to some but
not all of his examiners. Labs revealed Na 131, K 5.3 with
BUN/Cr of 37/4.0 and an anion gap of 16. Lactate was elevated
at 2.4. A FAST ultrasound was negative for bleed and CXR did
not show infiltrate. He was given 2g of calcium gluconate and
6L of IVF and a subclavian line was placed. He was making
urine. He was given 10mg of IV decadron for concern of adrenal
insufficiency. While he was in the ED, he denied suicidality or
ingestion of pills, even after he was seen in his room with an
open bottle of colace spilled in front of him. He was started
on dopamine just prior to being sent to the ICU.
Upon arrival to the ICU, he was resting comfortably in bed and
asking for ginger ale. He denied chest pain. He stated he had
had an episode of non-bloody emesis en route to the ICU,
although this was not reported by the staff who transferred him.
He also denied suicidality or medication overdose.
REVIEW OF SYSTEMS:
(+)ve: rinorrhea, sinus congestion, cough that had been
productive of green sputum but is now improving, myalgias, sore
throat, nausea, vomiting as above, diffuse abdominal pain,
thirst, shaking chills in hospital yesterday. +Poor vision [**2-4**]
right cataract
(-)ve: fever, night sweats, chest pain, palpitations,
hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
diarrhea, constipation, hematochezia, melena, dysuria, urinary
frequency, urinary urgency, focal numbness, focal weakness,
arthralgias
Past Medical History:
1. Seizure history - variably described as "[**Doctor Last Name 11332**] mal" or
"tonic-clonic" with bilateral arm shaking, no LOC. Was on
Trileptal in the past, but developed hyponatremia, now on
Keppra. Followed by Dr. [**First Name (STitle) 3322**] [**Name (STitle) **]. EEG negative 2/[**2132**].
2. Headaches - usually on left, radiating done back, sometimes
involving left face. Has been on narcotic meds for this.
3. Type II DM - A1C 7.7% in [**2132-11-2**]
4. Peripheral neuropathy
5. Hypertension
6. Dyslipidemia
7. Diastolic Dysfunction (EF 60-70% on recent echo with LVH)
8. GERD
9. Depression/Anxiety
10. Lumbar spinal stenosis w/ history C3/C7 fractures
11. Degenerative joint disease
12. Neurogenic bladder
13. s/p left cataract surgery
[**37**]. Vitamin B12 deficiency
15. Atypical chest pain (last MIBI negative [**3-10**])
16. h/o Hyponatremia, which resolved in fall [**2130**]
17. h/o multiple falls due to multifactorial gait ataxia, also
followed by Dr. [**First Name (STitle) 3322**] [**Name (STitle) **]
18. 8-mm thecal mass, stable over several years, consistent with
nerve sheath tumor.
19. Likely prior left temporal infarct (per atrophy on head MRI)
20. Multiple admissions to [**Hospital1 18**] (almost 20 this year), for
chest pain, hypotension with ARF, or aspiration. Had very
similar presentation [**2132-8-15**] with ARF and hypotension
21. Per prior records, has a h/o hoarding medications in the
hospital and then surreptitiously overdosing while in house
Social History:
Pt has been living on the street for the last several months.
Was engaged to a woman many years ago but broke it off. He
states he had many relationships, and used to be bisexual. Now
he is "celibate" since becoming a priest and is not in any
relationship. College graduate. Worked on Masters. Attended
nursing school. uddhist priest x 25 years. Was working to
counsel AIDS patients prior to becoming homeless. No social
supports in [**Location (un) 86**], but has a sister in [**Name (NI) **] with whom he is in
contact.
Lately, he has been living at the [**Hospital1 **], where he feels safe.
He has a case manager by the name of [**Male First Name (un) 19679**] who is helping to
find an apartment for him.
Per prior notes, pt has a history of sexual abuse by his
father's brother at age [**6-8**]. Never told anybody, no treatment.
Was also physically abused by his father growing up.
Smoked for 3 years in college. Denies alcohol or drug use.
Family History:
Mother died of esophageal cancer, ?EtOH abuse and depression.
Father died suddenly of heart attack.
Multiple family members with CAD including father, sister [**Name (NI) **] at
58 yo), all 4 grandparents
Type 2 DM (paternal grandfather)
Physical Exam:
VS: 96.5 95/47 82 17 98% RA
GENERAL: Pleasant, well appearing man in NAD
HEENT: Some well-healed scars on face. No conjunctival pallor.
No scleral icterus. Left surgical pupil. Right pupil is small
but reactive. Mucous membranes dry. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular, but borderline bradycardia in low 60s. Normal
S1, S2. No murmurs, no friction rub.
LUNGS: Good air movement but has coarse crackles at b/l bases
and some expiratory wheezes.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 intact apart from left
surgical pupil. Preserved sensation throughout. 4+/5 in
proximal LUE but otherwise strength is [**5-6**] throughout (pt
reports this is chronic from "neuropathy"). +Asterixis. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2132-12-15**] 01:00PM WBC-11.8* RBC-4.60 HGB-11.6* HCT-37.0*
MCV-80* MCH-25.2* MCHC-31.3 RDW-14.8
[**2132-12-15**] 01:00PM PLT COUNT-349
[**2132-12-15**] 01:00PM GLUCOSE-226* UREA N-37* CREAT-4.0*#
SODIUM-131* POTASSIUM-5.3* CHLORIDE-94* TOTAL CO2-21* ANION
GAP-21*
[**2132-12-15**] 01:00PM PT-12.4 PTT-24.3 INR(PT)-1.0
[**2132-12-15**] 01:00PM cTropnT-0.04*
[**2132-12-15**] 01:05PM LACTATE-2.4*
[**2132-12-15**] 02:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2132-12-15**] 04:38PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Studies:
[**2132-12-15**] Normal sinus rhythm. Tracing is within normal limits.
[**2132-12-15**] CXR: Persistent vague opacity in the left lower lung
likely represents atelectasis or pneumonia.
[**2132-12-15**] CXR: 1. Left subclavian catheter terminates at upper
SVC without pneumothorax. 2. Vague increase in left lung base
opacity may represent atelectasis vs pneumonia.
Brief Hospital Course:
69 year old gentleman with recurrent admissions for hypotension
+/- renal failure and aspiration presented with hypotension,
bradycardia and acute renal failure, which is thought to be due
to beta blocker and ACE inhibitor over dose.
#. Hypotension: He presented with hypotension felt to be related
drug overdose. Per review of his records, he has a history of
episodes of severe hypotension with systolic pressures in the
50s and 60s that prompt intubation, sepsis treatment, and ICU
admission with extremely rapid clinical improvement. In
addition, he was noted to hoard medications and take many pills
at once during his last admission and there was an episode in
the ED in which the team was concerned he was trying to take in
an entire bottle of colace. Though patient had a low morning
cortisol, he had a normal cortisol stimmulation test.
Multi-drug overdose seemed most consistent, especially as he was
both hypotensive and bradycardic. He was evaluated by
psychiatry who determined that this was not a suicide attempt,
however was likely poor medical management. He required
dopamine initially which was stopped on [**12-16**]. He was briefly
on antibiotics for possible sepsis but these were stopped the
morning after admission due to low clinical suspicion for
infection.
Given that the very likely reason for his multiple admissions
with hypotension and bradycardia are due to
overdose/inappropriate self administration of his
antihypertensives, these have been disconintued altogether. His
systolic blood pressure was 130-150s while off his blood
pressure medications and it is clear that the risks of him
continuing on these medications far outweght the risks.
#. Bronchiectasis: Bronchiectasis was found on chest CT during
this admission. Due to multiple drug allergies, he was started
on Vancomycin for suppressive therapy on [**12-16**] with planned
course of 10 days. He was also started on bronchidilator
therapy and may benefit from pulmonary hygiene therapy.
# Acute renal failure: His creatinine increased from 1.1 on his
recent discharge to 4.0 on admission. His renal function
recovered fully within few days and the acute failure is thought
to be due to Lisinopril overdose.
# Seizures: He was continued on Keppra during this admission.
# Type 2 DM and peripheral neuropathy: He was continued on
insulin, ASA, and gabapentin.
# H/o HTN: His home BP meds (amlodipine, metoprolol, imdur and
lisinopril) were held, and discontinued upon discharge, as the
self inflicted harm from this medication is thought to be
greated than potential long term benefit.
# Hyperlipidemia: Continued statin
# H/o Depression: Continued cymbalta. He did not endorse SI
and adamantly denied any ingestion other than prescribed
medications. He was seen by psychiatry who did not feel that he
needed 1:1 supervision but that he likely had difficulty
managing his medications as an outpatient.
# Chronic pain and spinal stenosis: Continued oxycodone
# Neurogenic bladder: Continued ditropan
# Access: He had a left subclavian CVL placed in the ED. This
was discontinued upon transfer to the floor.
# Code Status: Patient was FULL CODE during this admission.
Medications on Admission:
Amlodipine 10mg daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
Lisinopril 20 mg daily
Simvastatin 80 mg daily
Isosorbide Mononitrate 30 mg daily
Levetiracetam 1000 mg [**Hospital1 **]
Oxycodone 10 mg Q6H prn pain
Duloxetine 60 mg daily
Pantoprazole 40 mg daily
Trazodone 50 mg HS prn insomnia
Gabapentin 1200 mg Q12H
Aspirin 81 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Ditropan XL 5 mg [**Hospital1 **]
Humulin N 10 units s.c. qAM, 6 units s.c. qPM
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every eight (8)
hours as needed for pain.
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) 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. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Humulin N 100 unit/mL Suspension Sig: 10 units s.c. qAM, 6
units s.c. qPM units Subcutaneous twice a day.
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
15. Vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 7 days: last day
[**2132-12-25**] to finish a 10 day course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Hypotension and bradicardia
Bronchiectasis
Secondary:
1. Seizure disorder
2. Headaches
3. Type II DM
4. Peripheral neuropathy
5. Hypertension
6. Hypercholesterolemia
7. GERD
8. Depression/Anxiety
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You wewre admitted with low blood pressure and heart rate. You
were
found to have persistent MRSA bacteria in your sputum and a
chronic lung disease called: Bronchiektasis. You need to finish
a full course of itravenous antibiotic.
We have discontinued several of your medications (ACE inhibitor
and betablocker, see below), as we are concerned about proper
dosing and self administration, with secondary complication like
hypotension, bradycardia, and renal failure). Please stop taking
them.
Followup Instructions:
Please follow up with your primary care doctor within one week
after your discharge
Name: [**Known lastname 14859**],[**Known firstname **] J. Unit No: [**Numeric Identifier 14913**]
Admission Date: [**2132-12-15**] Discharge Date: [**2132-12-19**]
Date of Birth: [**2063-10-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Tetracyclines / Erythromycin Base /
Ciprofloxacin
Attending:[**First Name3 (LF) 4281**]
Addendum:
Multi disciplinary meeting was held today to develop a plan for
future care of Mr. [**Known firstname **] [**Known lastname **]. Meeting participants were Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Psychiatry), Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (primary care
physician), Dr. [**First Name (STitle) **] [**Name (STitle) **] (Hospitalist), Ms. [**First Name4 (NamePattern1) 6149**] [**Last Name (NamePattern1) 14921**]
(case managment), Ms. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (social work), Dr. [**First Name (STitle) **]
[**Name (STitle) 14922**] (medical resident).
Mr. [**Known lastname **] is a 69 year old male who over the past hear has been
admitted to the hospital 24 times ([**Hospital1 8**] alone). His
presentations are often similar, and mostly thought to be
related to medication intoxication (blood pressure medication,
sedatives, and narcotics).
On this admission it was decided to discontinue all blood
pressure medication as their long term benefit is overthrown by
their short term risk of not proper self administration.
Dr. [**Last Name (STitle) **] will be the only person giving him any kind of
prescription none should be provided to him on discharge, except
through specific request of his primary care doctor.
Protocol for all in hospital admissions:
1. ED alert - on d/c no prescriptions should be provided
2. All belongings searched and all medications to be put in to
patient safe
3. Case management and social work to be informed and meeting to
be held with patient's sister to be included in management plant
and discussions.
4. Formal neuro-psychiatric evaluation
5. Consider allergy consult and evaluation for allergies to
antibiotics, as the recorded allergies (anaphylaxis to
Sulfonamides, Penicillins, Tetracyclines, Erythromycin,
Ciprofloxacin) repeatedly made treatment and disposition
difficult. There is significant degree of suspicion whether
patient truly reacts with anaphylaxis to this medications.
If patient presents in the future with signs and symptoms,
thought to be due to self inflicted harm, than guardian ship
should be pursued after formal neuropsychiatric evaluation, and
discussion in multi disciplinary rounds.
if similar to consider guardian ship
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 4282**] MD [**MD Number(2) 4283**]
Completed by:[**2132-12-19**]
|
[
"345.90",
"357.2",
"V58.67",
"V02.54",
"300.4",
"V60.0",
"338.29",
"494.0",
"784.0",
"584.9",
"786.59",
"596.54",
"E950.4",
"972.6",
"428.32",
"401.9",
"530.81",
"272.4",
"V12.54",
"781.2",
"724.02",
"276.7",
"266.2",
"428.0",
"458.29",
"427.89",
"250.60",
"715.90",
"V15.88"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16956, 17169
|
7892, 11080
|
354, 379
|
13432, 13432
|
6852, 6852
|
14128, 16933
|
5628, 5868
|
11589, 13087
|
13204, 13411
|
11106, 11566
|
13608, 14105
|
5883, 6833
|
2604, 3121
|
303, 316
|
407, 2585
|
6868, 7869
|
13446, 13584
|
3143, 4638
|
4654, 5612
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,835
| 124,952
|
28872
|
Discharge summary
|
report
|
Admission Date: [**2153-5-26**] Discharge Date: [**2153-5-29**]
Date of Birth: [**2113-4-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Chief Complaint: nausea/vomiting
Reason for MICU transfer: hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
40 year old man with a history of abdominal pain who presents
with 1 day of beltlike abdominal pain.
The patient presents with nausea/vomiting and abdominal pain.
The abd pain began yesterday morning at dialysis. He developed
nausea and emesis, vomiting small amounts of liquid, non-bloody.
He describes the pain as [**9-19**] in a band-like distribution
across his umbilicus. He also had 2 loose non-bloody BMs. He is
c/o mild HA. The patient reported he took his morning
medications but did not tolerate medications since that time
missing his two PM doses of labetolol. He denies recent etoh
use, abdominal trauma. Presentation is typical to past. Onset
of abdominal pain 1 year prior and typically resolve only w/
hospitalizations. BPs at home can be as low as 170s when he
occasionally takes them but in general are high.
In the ED, initial VS were: 98.4 74 [**Telephone/Fax (2) 69665**]0% RA.
Physical exam significant for mild tenderness to palpation
across the epigastrum. No rebound/guarding. Positive bowel
sounds. Initial labs demonstrated a normal lipase of 49,
unremarkable chem10 and coags. Imaging was not pursued given
the patients typical symptoms and being well known to the
emergency staff. He was given zogran 4mg x 2, dilaud 1mg x 3
and ativan 2mg IV x 1. For management of his hypertension, he
was given IV labetolol 20mg x 2, and a 800mg PO tablet with
blood pressures stbly in the 180-200s. He was initially
assigned a general medical floor bed, however given concern for
requiring IV anti-hypertensives by the floor team, his
bed-assignment was changed to the MICU. Vitals on transfer
were: 77 99% RA 16 98.1 199/126. He was assymptomatic.
On arrival to the MICU, 97.8, 206/129, 96% RA, 15. He is
comfortable and c/o mild HA.
Past Medical History:
Past Medical History:
1. HTN
2. ESRD (on HD MWF), likely from HTN nephropathy per OMR
3. Asthma
Social History:
- etoh: had a small drink on [**Holiday 944**] day but used to drink
- tobacco: smokes 1 pack every 3 days
- illicits: prior marijuana and cocaine, none current
- employment: unemployed
- housing: alone
Family History:
1. Type 2 Diabetes (Mother, Brother, Father)
2. Pancreatitis (Brother)
3. Gastic cancer (uncle)
Physical Exam:
Vitals: 97.8, 206/129, 96% RA, 15
GENERAL - chronically- ill appearing man, sitting up comfortably
in
bed; appears mildly sedate, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM slightly dry,
OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2, 2/6 systolic murmur
ABDOMEN - NABS, soft, non-distended, mildly tender to palpation
of upper quadrants bilaterally, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no pedal edema, 2+ peripheral pulses
(radials, DPs); large left arm fistula with strong venous hum
SKIN - evidence of recently-peeled scabs arms and legs, some are
nodular.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION
[**2153-5-26**] 02:00PM BLOOD WBC-5.7 RBC-4.17* Hgb-11.2* Hct-34.9*
MCV-84 MCH-27.0 MCHC-32.2 RDW-20.6* Plt Ct-158
[**2153-5-26**] 02:00PM BLOOD Neuts-68.8 Lymphs-13.9* Monos-6.2
Eos-10.0* Baso-1.2
[**2153-5-26**] 02:00PM BLOOD Glucose-92 UreaN-28* Creat-7.4*# Na-140
K-4.4 Cl-94* HCO3-33* AnGap-17
[**2153-5-26**] 02:00PM BLOOD ALT-20 AST-18 AlkPhos-92 TotBili-0.9
[**2153-5-26**] 02:00PM BLOOD Lipase-49
[**2153-5-26**] 02:00PM BLOOD Calcium-10.3 Phos-PND
Brief Hospital Course:
Hospital Course: This is a 40 year old gentleman with a history
of pancreatitis who presented with 1 day of beltlike abdominal
pain.
***MEDICINE COURSE: PATIENT ELOPED FROM FLOOR ON [**5-28**] OVERNIGHT
WITH IV IN PLACE. BED WAS HELD FOR SEVERAL HOURS HOWEVER HE DID
NOT RETURN.***
# Hypertension: ***Note, patient has a long history of
non-compliance*** Longstanding HTN complicated by ESRD.
Assymptomatic and no evidence of end organ damage. Likely
exacerbated by inability to tolerate PO. Plan to control nausea,
restart home regimen and control HTN w/ prn IV labetolol and IV
hydralazine. Review of prior records reveals BPs during
admissions typically between 170-220s requiring IV control.
Denies active illicit drug use but consider possible ongoing use
including cocaine. He was started on his home regimen in the ICU
and given a 1x dose of hydralazine 10mg with improvement of BPs
to 140-170s. He was monitored on his home dose of amlodipine
10, lisinopril 40 and labetolol 800 tid for 24 hours. While at
dialysis, patient had SBPs in 180s-210s and was given several
doses of hydralazine with some effect. Patinet was started
nifedipine per renal recommendations. Ulimately plan was to
start hydralazine.
# Nausea/Emesis: Frequent admissions for chronic abdominal pain
attributed to pancreatitis exacerbations. Lipase normal as has
been in the past. The patient denies recent etoh use. No
recent abdominal trauma. Does not appear to have a regular PCP
or GI or significant past w/u for abdominal pain. Prior records
indicate h/o polysubstance abuse as outlined below. He was made
NPO given IV anti-emetics and IV pain medications initially and
was subsequently transitioned to PO medications and solid food.
# Per PCP, [**Name10 (NameIs) **] has polydrug abuse which includes IV
narcotics. He has a history of going to different medical
centers ([**Hospital1 112**], [**Hospital1 2177**], [**Hospital1 3278**]) and complaining of abdominal pain and
nausea in order to receive IV dilaudid. When he is refused IV
meds, he checks out AMA. There is a standing order at the other
three centers' EDs to not give him IV narcotics as there is also
some question of malingering.***
# Multiple Skin Nodules: Likely Kyrle??????s disease, an acquired
perforating dermatosis seen in ESRD vs less likely calcinosis
cutis. Does not appear to be pruritic or bothersome.
# ESRD: Secondary to longstanding hypertension. The patient
currently receives dialysis on a MWF schedule. He was continued
on calcium acetate and nephrolcaps.
Transitional Issues
# Communication: Patient, [**Country **],[**Name (NI) **] HCP [**Telephone/Fax (1) 69664**]
# Code: Full confirmed
Medications on Admission:
1. amlodipine 10 mg Tablet
2. lisinopril 40 mg Tablet 1 Tablet PO once a day.
3. labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID
4. calcium acetate 667 mg Capsule Four (4) Capsule PO TID w/
meals
5. albuterol sulfate 90 mcg/actuation 2 q4hrs prn SOB
6. B complex-vitamin C-folic acid 1 mg Capsule 1 daily
Discharge Medications:
eloped
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypertension
Secondary:
Chronic kidney disease
Discharge Condition:
eloped
Discharge Instructions:
eloped
Followup Instructions:
eloped
Completed by:[**2153-5-29**]
|
[
"303.93",
"V45.11",
"787.01",
"304.71",
"403.91",
"789.05",
"577.1",
"585.6",
"V15.81",
"577.0",
"493.90",
"V65.2",
"305.1",
"701.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7077, 7083
|
4011, 4011
|
380, 386
|
7184, 7192
|
3519, 3988
|
7247, 7284
|
2537, 2635
|
7046, 7054
|
7104, 7163
|
6711, 7023
|
4028, 6685
|
7216, 7224
|
2650, 3500
|
283, 342
|
414, 2180
|
2224, 2300
|
2316, 2521
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,577
| 114,752
|
51465
|
Discharge summary
|
report
|
Admission Date: [**2183-2-17**] Discharge Date: [**2183-2-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
[**Age over 90 **]year old male with h/o dementia, HOH, CAD s/p CABG, s/p PPM,
recent L hip fx s/p THA (fall) sent to [**Hospital1 18**] from [**Hospital1 **] [**Location (un) 16824**] after being found down this am. Pt not able to provide
history so history per ER records and daughter who is in
[**Name (NI) 108**]. Found on floor this am, no witnessed fall. Second fall
in past week. Per rehab, not communicative since arrival there,
very hard of hearing. Per daughter, has not recovered since
surgery, previously was communicating and walking around
independently as of the New Years until his fall and fracture.
Son-in-law and [**Name2 (NI) **] saw pt 3days ago and thought he
looked "terrible". No report of fevers/chills at [**Hospital1 1501**].
In ER, imaging w/o acute traumatic injury. Seen by ortho,
nothing to do and did not feel wound was infected. Found to be
in ARF [**3-10**] dehydration with Na 155, Creat 2.5 Got 2L IVF. Foley
placed. At some point, O2 sats decreased to 80%RA and HR
increased to 105 (Admitting MD NOT notified of this change) and
he was placed on O2. Recieved Vanc for possible wound infection
and levo for foul urine (UA negative). Also recieved ativan 1mg
IV for agitation and was placed in soft restraints. By time of
arrival to floor, pt is lying in bed, moaning insensibly,
opening his eyes to voice but not following commands.
ROS: unable to obtain given patient's current mental status
Past Medical History:
DJD
CAD s/p 4vCABG 25years ago, no h/o CHF (?ICM)
AV PPM for 2nd deg AVB [**2179**]
BPH
Alzheimer's dementia
Deaf-hard of hearing
L hip fx s/p bipolar hemiarthroplasty [**2182-2-7**] (fem neck fracture
s/p fall)
dyslipidemia
DM-new dx
depression
Hemmerhoids
nephrolithiasis
Social History:
Recently living at [**Hospital3 **] dementia unit (The Falls in
[**Location (un) 745**]) since [**1-13**] (independent living before that-->moved [**3-10**]
worsening dementia), then had fall with fracture and hip
surgery, now getting rehab at [**Hospital1 **] [**Location (un) 55**] since [**2182-2-10**].
No active tobacco, etoh. Pt is unable to provide further social
history regarding past use. wife died 2.5years ago and pt has
been depressed since.
Family History:
patient is unable to provide any family history at this time and
this is noncontributory given his age
Physical Exam:
On Presentation Per Admission Note:
Vitals: 98.0, 94/64, 108, 18, 97% 2L NC
General: Patient is an elderly male, moaning and calling out
intermittently. Patient opens eyes to yelling, does not follow
commands. Moving all limbs to painful stimuli. Patient yells out
when touching any part of body
HEENT: NCAT. Pupils 2-3mm bilaterally.
OP: MM very dry appearing
Neck: JVP appears 5-6 cm
Chest: Difficult to appreciate over moaning. Relatively clear
anterior
Cor: Irregular, II/VI systolic murmur at LUSB
Abd: Obese, soft. + BS. No guarding with exam
Rectal: Normal tone, large soft brown stool in rectal vault,
guaiac negative
Back: No sacral decubitus ulcer
Ext:
Left Hip with 10-12cm linear surgical wound with staples in
place, mild erythema surrounding wound. No obvious fluctuance or
induration
Pertinent Results:
ADMISSION LABS:
CBC: WBC 19.5 with 87%N HGB 8.8, HCT 26.7 MCV 93 per OSH
records: HCT 31.2 on [**2-10**] (post-op on discharge)
INR 1.3
Trop 2.2
Lactate 3.6-->2.9
Chem: Na 155, K 3.4, Cl 114, Bicarb 24, BUN 89, Creat 2.5
(baseline 0.8)
Ca, Mag, Phos wnl
CK 281
UA: [**7-16**] wbc, trace LE, no bacteria
UCx pending
IMAGING:
pCXR [**2183-2-17**]: IMPRESSION: No acute abnormality. Tortuous
thoracic aorta.
EKG: ?wavy baseline (afib vs NSR) with LBBB
Bilateral hips radiographs total of five views [**2183-2-17**]:
COMPARISON: No prior comparison available.
FINDINGS: There is no evidence of acute fracture or dislocation.
The left hip arthroplasty hardware is seen without evidence of
hardware complications. Surgical staples are seen projected onto
the left lateral pelvis. The visualized portion of the lower
lumbar is unremarkable. The sacroiliac joints are grossly
intact. There are degenerative changes of the hips with marginal
osteophytosis on both sides, right slightly more prominent than
left. There is underlying vascular calcification.
IMPRESSION: No acute fracture or dislocation. Uncomplicated
appearance of the left hip arthroplasty.
CT Head w/o contrast [**2-17**]:
IMPRESSION: No acute intracranial hemorrhage or fracture.
CT c-spine w/o contrast [**2-17**]:
IMPRESSION:
No acute fracture or malalignment of the cervical spine.
Multilevel
degenerative changes as noted, with a prominent posterior
osteophyte at the level of C5-C6.
RIGHT HUMERUS, TWO VIEWS. RIGHT SHOULDER, TWO VIEWS. RIGHT HAND,
THREE
VIEWS [**2183-2-20**]:
RIGHT SHOULDER: Probable diffuse osteopenia. No fracture or
dislocation
detected involving the right shoulder. A pacemaker type device
is noted.
RIGHT HUMERUS, TWO VIEWS: No fracture is detected involving the
right
humerus. If there is high clinical concern for an elbow injury,
then
dedicated views would be recommended. No obvious elbow
derangement is
detected on these views.
RIGHT HAND, THREE VIEWS: There is diffuse osteopenia. There is
background
osteoarthritis, including narrowing and subluxation at several
MTP joint.
There is diffuse soft tissue swelling. The AP view raises the
question of
slight deformity at the base of the fifth metatarsal -- the
possibility of an occult fracture at the base of the fifth
metatarsal cannot be entirely
excluded. Otherwise, no fracture is detected involving the right
hand.
IMPRESSION:
1. Moderately-severe diffuse osteopenia.
2. Prominent soft tissue swelling about the hand.
3. Subtle deformity base of right fifth metacarpal bone raising
question of a possible occult fracture. Is there point
tenderness in this location? If symptoms persist, consider
followup x-ray in [**6-12**] days to assess for changes about a
potential occult fracture.
4. No fracture or dislocation involving the right shoulder. No
fracture
detected involving the right humerus.
TTE [**2183-2-19**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is mildly depressed (LVEF= 45-50 %) with
infero-lateral hypokinesis. There is no ventricular septal
defect. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**2183-2-17**] 8:46 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2183-2-23**]**
Blood Culture, Routine (Final [**2183-2-23**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2183-2-18**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2183-2-18**] @ 9:10 P.M..
[**2183-2-18**] 9:21 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 265-4109W [**2183-2-17**].
Anaerobic Bottle Gram Stain (Final [**2183-2-20**]):
GRAM POSITIVE COCCI IN CLUSTERS.
CXR [**2183-2-19**]:
FINDINGS: Interval placement of left-sided PICC with tip at the
low
SVC/cavoatrial junction. Transvenous pacing leads in standard
positions.
This is a technically limited evaluation secondary to rotation.
The lungs are
grossly unchanged from prior examination. The cardiac and
mediastinal
contours are stable.
: Interval placement of left PICC with tip ending at low
SVC/cavoatrial junction.
.
Hip Xray [**2183-2-24**]
IMPRESSION
INDINGS: Compared to [**2183-2-17**], there has been little
interval change
in the appearance of a patient status post left
hemiarthroplasty. Allowing
for marked positional differences between two studies, there has
been no
change in the position of the hardware. Joint space narrowing
related to
degenerative change in the right hip. Vascular calcifications
are present.
Sacroiliac joints appear normal. The pubic symphysis is normal.
The sacrum
is obscured by overlying bowel gas.
IMPRESSION: Stable appearance of left hemiarthroplasty without
dislocation.
.
LLE Ultrasound [**2183-2-26**]: No DVT
Brief Hospital Course:
[**Age over 90 **] year old male with history of reported dementia, heard of
hearing, CAD s/p CABG, Afib s/p PPM who recently was admitted to
[**Hospital6 **] for a left hip fracture after fall,
who was found down at his NH. He was initially admitted to the
floor but was found to be intermittently hypotensive and
hypernatremic with a sodium of 160 and was transferred to the
ICU for more acute management. Hypernatremia was treated with
D5W and resolved. The patient was initially continued on
vanc/zosyn for broad spectrum coverage pending culture data.
Patient also had elevated CK/troponins. Initally treated with
heparin gtt which was d/c'ed as on re-evaluation the patient's
troponin elevation was likely secondary to ARF.
The patient was transferred from the ICU to the medicine service
on [**2-20**].
# MRSA Bacteremia: Pt's blood cultures on [**2-17**] noted to grow
MRSA x 2 bottles, culture and blood culture on [**2-18**] also grew
MRSA. Unclear as to the source of the bacteremia, pt did
recently undergo hip replacement however his left hip did not
show any gross evidence of infection, no pnuemonia had been
noted on chest x-rays. Pt was started on Vancomycin on [**2-17**]. Pt
was also started on Zosyn however given the results if the
positive blood cultures it was d/c'd on day #3. TTE did not
reveal any evidence of endocarditis. On [**2-22**], an extensive
discussion was held with the patient's daughter and son
regarding goals of care. The patient's son and daughter did not
want any invasive procedures such as a TEE, IR-aspiration of
fluid around the patient's hip or explantation of the patient's
pacemaker. Given the potential for endocarditis, osteomyelitis,
and pacemaker infection, a 6 week course of Vancomycin was
agreed upon. The patient has a high possibility of becoming
reinfected after his antibiotics are stopped given that he has
hardware in place. While on Vanc, the pt will need weekly
troughs, CBC, and creatinine checked. Due to trough of 6.0 on
Vanc 1 gm daily, Vanc was increased to 1 gram twice daily. His
trough was 19.6, so dose was decreased on day of discharge to
750 mg twice daily (will receive his first dose of this after
discharge). He needs a repeat Vanc trough the AM prior to his
[**2-28**] dose. Goal trough close to 15.
.
# Delirium on underlying mdoerate Alzheimers dementia) [**Doctor Last Name **]
and waxing with multiple etiologies contributing. The patient
had recent hip operation, bacteremia, various hospitalizations
contributing. At times he yells "help,help" and at other times
he is more somnolent and does not answer questions. His delirium
will likely take weeks to resolve. He was followed by geriatrics
consult here. They recommended not restarting his ativan and not
to restart him on paxil (given its anticholinergic properties).
The patient also would benefit from long term placement as prior
to several months ago he had been living independently and he
has now had a significant decline in function. Suspect pt will
not return to his baseline. Pt had been living in an [**Hospital 4382**] facility prior to recent hip fracture. At time of
discharge, pt was more interactive, eating (with 1:1
assistance), but confused and does not know where he is.
.
# Hypotension: The patient was hypotensive on the floor,
possible contribution of hypovolemia and preseptic physiology
given MRSA bacteremia. This resolved with IV fluids. His
atenolol has been restarted, but not his cardizem or imdur.
.
# Hypernatremia - Secondary to free water deficit, calculated at
5.6 liters. Treated with D5W and it resolved. The patient is at
risk for dehydration and readmission for hypernatremia in the
future given his poor po intake. If he is admitted for
dehydration, then PEG placement for fluid purposes will need to
be discussed. At this time, pts family would like to minimize
invasive procedures and defer discussion of PEG placement unless
absolutely necessary.
.
# Acute Renal Failure: Secondary to significant hypovolemia.
Improved with volume resuscitation, good urine output.
Creatinine back to 0.7 at discharge.
.
# Hypoxia, transient: Unclear actual oxygen requirement on the
floor. O2 sat confirmed 97% on 2L NC with ABG on floor prior to
ICU transfer. Repeat CXR without obvious infiltrate or volume
overload. Patient satted well on room air at discharge.
.
# S/p recent left hip fracture - Incision appears c/d/i, but
again, concern for underlying hardware infection/osteo based on
MRSA bacteremia and recent surgery. Pain control with
tylenol/oxyocodone as needed. Staples were removed. Pt will need
to continue lovenox until [**3-11**]. As noted above, pts family does
not want any invasive work up for osteomyelitis diagnosis. Of
note, due to LLE swelling day of discharge, obtained LE
ultrasound which showed no evidence of DVT.
.
# Urinary Retention: After removal of his foley, pt was noted
to have urinary retention. Initially he was straight cathed
every 6 hours, but this began to become traumatic with blood
clots. A foley was replaced. UA negative for infection. Not
receiving any offending medications (not receiving morphine). Pt
has not been receiving his terazosin, which may be contributing
to his retention. After he had his speech and swallow eval,
terazosin was restarted. He should have a voiding trial in 1
week after discharge, which should be enough time for his
terazosin to take effect.
.
# CAD: Initially held BP meds given hypotension. Continued ASA
and statin. Atenolol was restarted once taking po meds. Imdur
can be restarted if pt has room with his BP.
.
# Atrial fibrillation s/p PCM: Continued on ASA, no coumadin
given fall risk. Restarted atenolol once taking po. Cardizem
held and can be restarted if pt becomes hypertensive or
tachycardic.
.
# Diabetes Mellitus II, controlled, without complications: On
sliding scale insulin with lantus 5 U started on day of
discharge. As pt eats more, he likely will have more long acting
insulin needs.
.
# Hard of hearing: Pt can only hear with headphones/microphone.
.
# Hypocalcemia/Hypophosphatemia: Likely Vitamin D depletion.
Given Vit D 50,000 U x1. Would give another dose weekly for 3
more weeks and then daily repletion with [**Telephone/Fax (1) 106706**] U a day.
.
# HTN, benign: Initially held BP meds in setting of hypotension.
Atenolol was restarted once taking po and BP was improved.
Cardizem 120 mg daily and imdur 30 mg daily still on hold given
borderline low blood pressure (systolic in 100s). Cardizem can
be restarted as well as imdur if BP tolerates.
.
# Anemia: Hct was 23-25 while here. B12/folate WNL. Likely
anemia of chronic disease. Pt does have OB+ stool, but brown
loose on exam. He received a PRBC transfusion on [**2-25**]. Hct rose
to 26.1 prior to discharge.
.
# FEN: Per speech and swallow-pt can take soft solids, nectar
thick liquidis, crushed meds, 1:1 supervision; repeat swallow
eval in [**3-12**] weeks at rehab.
.
# Proph: Lovenox SC bid for 1 month following hip fracture (Day
1 approx [**2-8**])
.
# ACCESS: PICC
.
# Code: DNR/DNI, no pressor support or feeding tube placement.
Transfer to ICU OK, but no invasive procedure.
.
# Communication: Daughter [**Name (NI) **] [**Name2 (NI) **] in [**State **]: [**Telephone/Fax (1) 106707**] cell: [**Telephone/Fax (1) 106708**], son-in law: [**Telephone/Fax (1) 106709**] (home),
[**Telephone/Fax (1) 106710**] (cell)
.
Medications on Admission:
per [**Hospital1 1501**] list:
simva 20
ASA 81 chew
ISMN 30mg qd
cardizem CD 120 qd
atenolol 25mg qd
lovenox 30mg qd, plan for 4weeks
terazosin 2mg qhs
paxil 20mg qd
SSI-regular insulin
ativan 0.5mg [**Hospital1 **] prn
tylenol prn
oxycodone 5mg q4prn
vicodin 5/500 prn
colace [**Hospital1 **], dulocolax 10mg qd prn, mOM prn, [**Name2 (NI) **] enema prn
MVI c minerals
ground diet with thin liquids and diabetic supplements
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours): STOP AFTER [**2183-3-11**].
2. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): For FS of: 150-199 give 2 U,
200-249 give 4 U, 250-299 give 6 U, 300-349 give 8 U, 350-400
give 10 U.
3. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week for 3 doses: First dose to be given [**3-4**] Tuesday.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Vancomycin 750 mg IV Q 12H
Day #1 [**2183-2-17**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Delirium
MRSA bacteremia
Hypernatremia
Dehydration
Acute urinary retention
Acute renal failure
Discharge Condition:
stable
Discharge Instructions:
You were admitted with delirium (altered mental status), and
found to be dehydrated with high sodium levels. You also were
noted to have acute renal failure which has resolved. You were
found to have a bacteria growing in your blood called MRSA.
.
You will need to complete 6 weeks of antibiotics to cover for
potential infection of your hip as well as your pacemaker. On
discussion with your family, it was decided not to further
pursue a TEE (echocardiogram of your heart by doing a procedure
down your esophagus) or to pursue aspiration of your left hip.
It is possible this antibiotic course will not clear your
infection.
.
Due to retention of urine while holding your terazosin, we had
to place a foley.
.
Your cardizem and imdur have not been restarted yet.
.
Call your doctor or return to the ER for any worsening
confusion, fever, worsening hip pain, chest pain, shortness of
breath, or any other concerning findings.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 104493**] [**Hospital 1411**] medical
Group-[**Telephone/Fax (1) 8506**] after discharge from rehab. Fax:
[**Telephone/Fax (1) 8512**], [**Location (un) 58062**], [**Location (un) 1411**], [**Numeric Identifier 9310**].
.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,007
| 147,371
|
50394
|
Discharge summary
|
report
|
Admission Date: [**2156-12-18**] Discharge Date: [**2157-2-4**]
Date of Birth: [**2106-9-27**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Perineal pain
Major Surgical or Invasive Procedure:
Debridement ([**12-18**])
End colostomy ([**12-19**])
Rectal skin graft ([**1-24**])
History of Present Illness:
Ms. [**Known lastname **] is a 50-year-old wound, with diabetes,
who presented to an outside hospital with perineal
induration, pain and erythema. A CT scan was obtained
demonstrating necrotizing fasciitis of the buttocks, pubis,
and what appeared to be anorectal sepsis. The patient, after
being evaluated, was transferred to [**Hospital6 649**] for definitive care. Given her degree of
sepsis, she was admitted for emergent surgery, as discussed with
the hospital administrator, as well as the patient's court
appointed guardian.
Past Medical History:
DM
Schizoaffective D/O, bipolar type
obesity, HCV+, HBV+
Social History:
Court appointed guardian [**Name (NI) **] [**Name (NI) 105025**] [**Telephone/Fax (1) 105026**]; resides in
VinFEn housing at [**Location 105027**]in [**Hospital1 3494**] [**Telephone/Fax (1) 105028**].
Husband [**Name (NI) **] [**Name (NI) 105029**]. Married.
Pertinent Results:
[**2156-12-18**] 09:25PM LACTATE-3.8*
[**2156-12-18**] 09:00PM GLUCOSE-204* UREA N-13 CREAT-0.8 SODIUM-144
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-24 ANION GAP-15
[**2156-12-18**] 09:00PM ALT(SGPT)-18 AST(SGOT)-27 CK(CPK)-189* ALK
PHOS-102 AMYLASE-50 TOT BILI-0.8
[**2156-12-18**] 09:00PM PT-13.3 PTT-22.3 INR(PT)-1.1
[**2156-12-18**] 09:00PM WBC-14.4* RBC-4.44 HGB-13.3 HCT-38.8 MCV-87
MCH-30.0 MCHC-34.4 RDW-13.1
[**2156-12-18**] 09:00PM NEUTS-68 BANDS-19* LYMPHS-6* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
Brief Hospital Course:
[In brief summation, Ms [**Known lastname **] [**Last Name (Titles) 1834**] two debridements ([**12-18**]
and [**12-19**]) and a diverting colostomy ([**12-19**]) and skin graft ([**1-24**])
by plastics during this hospitalization.]
After being taken to the OR for wide buttock and perineal
debridement into muscle, she was taken to OR again the following
day for I&D of perirectal abscess and diverting sigmoid
colostomy. She experienced increased WBC post op. Infectious
disease was consulted and recommendations appreciated. Wound Cx
at OSH rare bacillus; wound cx from OR [**12-19**] w/ mod
corynebacterium, also coag negative
staph/peptostreptococcus/rare GNR. She was treated empiric with
clinda/vanc/levo/flagyl while in the ICU. A vac dressing was
placed to perineum on [**12-23**]. After spiking a temp of 101 with a
WBC rise up to 27.6, she went for abd CT to r/o intraabdominal
fluid collection; CT was negative. By [**12-28**], pressors were weaned
off and her fever curve had improved. She was intubated and
self-extubated on [**2156-12-30**]. Antibiotics were discontinued [**1-3**].
She was given fluconazole for coverage of significant vaginal
yeast.
Anal Manometry study was performed [**1-17**] and found be normal with
some hypersensitivity to balloon dilation. Subsequently the
recommendation made by Colorectal surgery was to repeat
manometry in [**1-21**] months for follow-up for possible
reconstruction given potential for continence. With Colorectal
deferring, plastics made decision to perform skin graft to
perineum. She [**Date Range 1834**] skin graft by PRS on [**1-24**] with use of
graft source from thigh. On POD#3 after undergoing skin graft,
patient self-dc'ed vac dressing from perineal area, leading to
failure of graft. Subsequently plastic surgery made the decision
to hold off on repeating the skin graft till follow up
re-evaluation in 3 weeks.
Patient was deemed stable and suitable for discharge on
POD#46/#45/#11, HD#49 with follow-up instructions as stated
below.
Medications on Admission:
depakote 250 qam, 500 qpm, zyprexa 20', benadryl 50', Vit E
Discharge Medications:
1. Olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous [**Hospital1 **] (2 times a day).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO Q HS
().
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
13. Morphine Sulfate 10 mg/5 mL Solution Sig: One (1) PO Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] MANOR
Discharge Diagnosis:
Fournier's gangrene
Necrotizing fascitis
Morbid obesity
Bipolar
DM
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP.
[**Name10 (NameIs) **] [**Hospital1 **] W->D dressing changes and Xeroform to skin graft.
Followup Instructions:
F/U with Plastics ([**Doctor Last Name 3228**]) in 3 weeks.
F/U with [**Doctor Last Name **] in 3 weeks.
F/U with Colorectal Surgery in [**1-21**] months for repeat manometry.
Completed by:[**2157-2-4**]
|
[
"070.70",
"038.8",
"518.81",
"112.1",
"250.00",
"566",
"295.32",
"785.4",
"996.52",
"278.01",
"995.92",
"569.69",
"728.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"86.69",
"86.22",
"93.59",
"83.44",
"83.45",
"46.11",
"86.74",
"48.82",
"89.39",
"96.6",
"99.15",
"48.81",
"99.04",
"00.17",
"71.79"
] |
icd9pcs
|
[
[
[]
]
] |
5093, 5146
|
1864, 3878
|
285, 372
|
5257, 5263
|
1313, 1841
|
6165, 6371
|
3988, 5070
|
5167, 5236
|
3904, 3965
|
5287, 6142
|
232, 247
|
400, 936
|
958, 1016
|
1032, 1294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,291
| 178,722
|
37264+58139
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-11-24**] Discharge Date: [**2200-12-2**]
Date of Birth: [**2147-9-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
-Temporary HD catheter placement and removal
-hemodialysis *1
History of Present Illness:
Mr. [**Known lastname 83881**] is a 53 year old man with recent THR, HTN, and
diabetes on insulin who was found unresponsive sitting in a
chair in his halfway house by his superintendent. He was
reportedly sitting in a chair and was completely unresponsive.
When EMS arrived they found him unresponsive and non-verbal but
with stable vital signs. He was given 0.4mg naloxone with no
response. On route to the hospital he vomited a small amount.
In the ED he was unresponsive but was moving his head around.
His vital signs in the ED were T 98.8 HR 88, BP 124/66 RR 11
saturating at 97% on room air. Ct head and spine were
unremarkable. Chest xray was also unremarkable. Urine tox was
positive for opiates. Serum tox was negative. UA was negative
for leukocytes and nitrites; WBC [**11-28**], large blood, RBC
negative. Patient had a leukocytosis with a WBC of 22. He was
given 1 dose of vancomycin. His creatinine was elevated to 8.9
(baseline 0.8) and he had a potassium of 6.3 with peaked T
waves. Patient was given bicarb, insulin, and glucose and his
potassium decreased to 5.1. No kayexelate was given due to
patient's altered mental status. Nephrology was consulted and
recommended rehydration at 125cc/hr, potassium checks, renal US
with doppler, and PTH level. Patient was given a total of 2L NS
in the ED and then admitted to the intensive care unit where he
was moving all four extremities but only rarely followed
commands and was not reliably responsive to voice.
Past Medical History:
-Hypertension
-Diabetes mellitus on insulin (A1C 6.3% on [**2200-10-29**])
-Hypertensive cardiomyopathy (last ECHO 35% EF with
septal/inferior hypokinesis)
-Hepatitis C Virus (never treated)
-h/o cholecystitis
-s/p hip replacement
-Gambling addiction
-h/o EtOH and cocaine abuse, sober since [**2195**]
Social History:
Patient has lived at the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] House where he has lived
for the past three years. He reports that he stopped drinking
and cocaine several years ago. He receives health care through
health care for the homeless. Patient has long standing history
of smoking and continues to smoker.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
T 98.8 HR 88, BP 124/66 RR 11 saturating at 97%
General: easily awaked and startled, non-verbal
HEENT: NC/AT, will not allow me to open eyes well but pupils
appear 2mm and symmetric
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally but difficult to assess with
rhonchorous upper airway sounds
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted, no fistula, no medical patches
Neurologic: limited exam
-mental status: drowsy but arousable with follow a few commands:
smiled symmetrically once, squeezed right hand but then would
not follow further commands, when arm raised above head patient
does not allow arm to fall on his face, when turned patient
grabbed out to stabalize himself
-cranial nerves: unassessable but symmetric smile
-motor: normal bulk, strength and tone throughout. not moving
extremeties
-DTRs:1+ biceps, brachioradialis, 2+ patellar and 1+ ankle jerks
bilaterally. Plantar response was flexor bilaterally.
+myoclonus
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-22.1* RBC-3.95* Hgb-13.1* Hct-39.0* MCV-99* RDW-13.6 Plt
Ct-191
---Neuts-77.3* Lymphs-16.1* Monos-6.0 Eos-0.3 Baso-0.2
PT-13.8* PTT-23.4 INR(PT)-1.2* Fibrino-353
UreaN-51* Creat-9.0*
ALT-54* AST-81* LD(LDH)-506* AlkPhos-148* TotBili-0.5
Albumin-4.2 Calcium-8.7 Phos-7.9* Mg-1.9
Osmolal-317*
On Discharge:
WBC-12.4* RBC-3.12* Hgb-10.3* Hct-32.6* MCV-99* RDW-13.2 Plt
Ct-220
Glucose-239* UreaN-22* Creat-1.2 Na-137 K-4.1 Cl-101 HCO3-27
ALT-35 AST-28 CK(CPK)-614* AlkPhos-96 TotBili-0.8
Calcium-9.1 Phos-2.9 Mg-1.6
Other Important Labs:
CK Trend
[**2200-11-24**] 04:20PM CK(CPK)-5015*
[**2200-11-24**] 11:20PM CK(CPK)-6561*
[**2200-11-25**] 04:28AM CK(CPK)-6445*
[**2200-11-25**] 08:34PM CK(CPK)-4367*
[**2200-11-26**] 06:03AM CK(CPK)-3207*
[**2200-11-26**] 05:07PM CK(CPK)-[**2191**]*
[**2200-11-29**] 11:06AM CK(CPK)-614*
Cardiac Enzymes:
[**2200-11-24**]: cTropnT-0.05*
[**2200-11-25**]: cTropnT-0.07*
Serum Tox:ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Urine Studies:
--------------
Tox Screen [**2200-11-24**]: bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2200-11-24**] Osmolal-521
[**2200-11-24**] Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.026
Blood-LG Nitrite-NEG Protein-75 Glucose-1000 Ketone-NEG
Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
UreaN-398 Creat-327 Na-33 CastGr-0-2 CastHy-[**6-18**]*
RBC-0-2 WBC-[**11-28**]* Bacteri-MOD Yeast-NONE Epi-0 TransE-0-2
[**2200-12-1**] Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
Blood-MOD Nitrite-NEG Protein-TR Glucose-300 Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
RBC-31* WBC-2 Bacteri-NONE Yeast-NONE Epi-0
CastHy-1*
=============
MICROBIOLOGY
=============
Blood Cultures *3: No growth
Nasal MRSA Screen: Positive for MRSA
Urine Culture*2:NGTD
===============
OTHER STUDIES
===============
EKG ([**2200-11-24**]): Normal sinus rhythm, rate 98, with probable left
atrial abnormality. Delayed precordial R wave progression,
possibly a normal variant, possibly anterior myocardial
infarction of indeterminate age. Non-specific inferolateral
repolarization changes.
CT Head and C-spine ([**2200-11-24**]):
1. No acute fracture or misalignment of the cervical spine.
Multi-level
posterior osteophytes which increases risk of spinal cord
injury. MRI is more
sensitive for evaluation of spinal cord or ligamentous injury.
2. Mild paraseptal likely bullous changes of bilateral lung
apices. Miniscule
left apical pneumothorax can not excluded. Follow-up suggested.
3. 1.6 cm right thyroid nodule. Ultrasound on a non-emergent
basis is
suggested.
CXR ([**2200-11-24**]):
Severely limited study due to obscuration of the lung apices by
the head, otherwise no acute intrathoracic abnormality.
Abd U/S ([**2200-11-25**]):
1. Stones and debris in the gallbladder.
2. No evidence of stones or hydronephrosis bilaterally.
CT Head w/o Contrast ([**2200-11-26**]):
1. No acute intracranial hemorrhage. No significant change since
the prior
study.
2. No soft tissue stranding or any significant abnormalities
seen within the subcutaneous tissues to explain etiology of
drainage.
Left Foot Radiograph ([**2200-11-29**]):
REASON FOR EXAM: Pain in the lateral aspect.
There is a question of a fracture in the distal phalanx of the
fifth digit. There is no evidence of dislocation, sclerotic
lesions or soft tissue calcifications. There is edema in the
soft tissues adjacent to the base of the fifth metatarsal. The
fifth metatarsal is normal. There is a small enthesophyte at the
insertion of the Achilles tendon.
Chest Radiograph ([**2200-12-1**])
IMPRESSION: Improving bibasilar opacities with residual right
infrahilar
opacity likely due to atelectasis. No definite new source of
infection.
Brief Hospital Course:
Mr. [**Name13 (STitle) 83882**] is a 53 year old gentleman with past medical history
notable for HTN, diabetes mellitus, and recent total hip
replacement found unresponsive in his halfway house with
rhabdomyolysis and acute kidney injury.
1. Altered Mental Status:
The patient presented with altered mental status of unclear
etiology. He was moving all four extremities and
hemodynamically stable and afebrile but minimally responsive to
commands. Particularly given his leukocytosis occult infection
was a major concern but he remained afebrile, chest radiograph
and urinalysis were not consistent with infection, and patient
never had meningismus or clinical signs of acute bacterial
meningitis. He received one dose of vancomycin at presentation
for unclear reasons. Blood cultures remained sterile.
Toxicology screen was only notable for opiates, which the
patient had been prescribed as he recovered from his hip surgery
and he had not responded to naloxone on EMS arrival. There was
no osmolar gap and the patient's head CT was essentially benign.
Given acute kidney injury uremia was thought to be a possible
cause of encephalopathy and he was dialyzed *1 with rapid
improvement of his mental status and increased responsiveness.
The patient dramatically improved over the ensuing day and
returned to baseline. He remained with poor memory of the
events leading to his presentation but could recall other events
and converse in a reasonable manner. Unfortunately, due to the
patient's habitus an initial attempt at an LP was unsuccessful
and given his dramatic resolution with dialysis, decreasing
leukocytosis, lack of fever, and ability to deny headache it was
not considered necessary to reattempt. Likely cause of
somnolence/delirium at presentation is thought to be uremia
though the initial insult that caused patient to be immobile and
develop rhabdomyolysis leading to [**Last Name (un) **] and uremia is unclear. At
the time of discharge patient's mental status was at baseline.
* Oliguric Acute Kidney Injury:
On presentation the patient had a Cr of 9 up from a baseline
reported at 0.8. Given urinalysis findings of large blood on
dipstick without cells and grossly elevated CK most likely
etiology was thought to be rhabdomyolysis and myoglobinuria
causing acute kidney injury. Obstruction and postrenal insult
was essentially ruled out by normal ultrasound. Nephrology was
involved in course from the ED where they recommended fluids.
The patient eventually put out very poor urine and given this,
his metabolic abnormalities (including hyperkalemia and
hyperphosphatemia), and his continued alteration of mental
status he had a temporary dialysis catheter placed and received
HD *1 with rapid resolution of his metabolic abnormalities and
mental status. Shortly after that he began a brisk diuresis and
required no further HD sessions or acute management of
electrolyte abnormalities. Therefore, his HD catheter was
removed. His Cr was down to 1.2 at the time of discharge.
* Rhabdomyolysis
At presentation the patient had clear rhabdomyolysis and
resulting kidney injury with elevated CK's and urine dipstick
with large blood but few RBC's on microscopy suggestive of
myoglobinuria. It was suspected the patient's rhabdomyolysis
was secondary to prolonged immobilization in his chair and over
his hospitalization he developed skin and tissue breakdown also
suggestive of a prolonged immobilization. The reason for this
prolonged immobilization is unclear. The patient's CK fell with
fluids and improvement in his renal function and the last time
it was checked it was slightly more than 600.
* Left Foot Vesicle
The patient had hyperkeratotic, cracked skin on his feet and was
noted to develop a large vesicle on his left lateral sole. This
was evaluated by podiatry who lanced it yielding serous material
without frank purulence. They did not recommend antibiotics and
these were not started. The patient was discharged with
outpatient podiatry follow-up.
* Skin Breakdown
The patient was noted to have skin breakdown with what looked
like a friction ulcer in his gluteal cleft. This was evaluated
by wound care who also noted areas of deep tissue injury and
other ulcers on his lower body. These were thought consistent
with a prolonged immobilization with some friction injury from
sliding or unintentional movements while unconscious in a chair.
These were all evaluated and showed no signs of acute
infection. Wound care was implemented and the patient will have
VNA to help continue this care as an outpatient.
*Hypertension
The patient became hypertensive on his second hospital day and
thus was restarted on his metoprolol and nifedipine at home
doses. His lisinopril was held given he had acute kidney
injury. As his Cr was close to baseline (down to 1.2) and he
was becoming more hypertensive again (SBP's in the 140's) his
lisinopril was restarted at half dose (20 mg daily) on the day
of discharge. He will follow up with his PCP to discuss when to
increase this back to his standard home dose.
*Diabetes
The patient was continued on his home insulin glargine dose as
well as insulin sliding scale. His AC doses and metformin were
held in the context of hospitalization and he was given sliding
scale with reasonable control of his blood sugars. His AC
humalog and metformin were restarted at discharge. Given the
patient evidenced minimal understanding of his diabetes or its
management he received diabetes education in house and was set
up to receive more as an outpatient. As he ran quite
hyperglycemic in general it was considered safe to discharge him
on his home scheduled insulin regimen with greater understanding
required to start sliding scale at home.
* Slightly elevated LFT's:
On day of admission patient had elevated LFTs with an ALT 54,
AST 81, Alk Phos 148, Tbili 0.5. Patient had gall stone on
abdominal US. With improvement of mental status patient had
benign abdominal exam with no nausea or vomiting. LFTs were
followed and normalized. Most likely etiology of
* Diabetes
Patient has insulin dependent diabetes. He was started on an
insulin sliding scale here in the hospital. An outpatient
podiatry appointment was set up for him.
*Hypertensive Cardiomyopathy
The patient remained without signs of volume overload or
clinical heart failure. He was continued on his beta blocker
and ACEi was restarted prior to discharge.
The patient was kept on subcutaneous heparin for DVT
prophylaxis. There was no indication for GI prophylaxis so this
was not started. He was full code. He tolerated a full diet
prior to discharge.
Medications on Admission:
toprol XL 200mg QD
nifedipine 120mg QD
lisinopril 40mg qd
aspirin 81mg qd
naproxen 500mg [**Hospital1 **]
lantus 58 units/day
metformin 500mg [**Hospital1 **]
humulog 6u AC
nitrostat prn
tramadol 50mg 1-2 tabs q6h prn pain
citalopram 20mg qd
Discharge Medications:
1. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Nifedipine 60 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lantus 100 unit/mL Solution Sig: Fifty Eight (58) units
Subcutaneous once a day.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous
TID w/ meals.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO four times
a day as needed for fever or pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
Altered Mental Status
Rhabdomyolysis
Oliguric Acute Kidney Injury
Secondary Diagnosis
Hypertension
Diabetes Mellitus
Discharge Condition:
Stable, tolerating PO
Discharge Instructions:
You came into the hospital because you were found unresponsive
in your home. No cardiac, neurological, infectious, or toxic
reason was found for your unresponsiveness.
When you came into the hospital you were found to have damaged
your kidneys and you were started on intravenous fluids. You
also had one session of hemodialysis to remove some of the
toxins from your blood that had accumulated given your poor
kidney function. During your stay in the hospital your kidney
function improved dramatically and returned to near baseline on
your discharge from the hospital. To keep your kidneys healthy,
we recommend that you continue to drink over 1L of water each
day.
While your kidneys recover we held and then restarted at a lower
dose your lisinopril. Otherwise please continue to take your
medications as previously prescribed.
Should you develop any concerning symptoms, including shortness
of breath, chest pain, severe abdominal pain, nausea/vomiting,
fever, blurry vision, headache, you should seek immediate
medical attention.
Followup Instructions:
PODIATRIST
Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 7749**]
Tueday, [**12-9**], 1:45pm
[**Location (un) 83883**], [**Location (un) **]
[**Telephone/Fax (1) 83884**]
PRIMARY CARE
Dr. [**Last Name (STitle) 11435**]
[**2201-12-12**]:30am
[**Street Address(1) **] Clinic
[**Telephone/Fax (1) 83885**]
Name: [**Known lastname 13344**],[**Known firstname **] Unit No: [**Numeric Identifier 13345**]
Admission Date: [**2200-11-24**] Discharge Date: [**2200-12-2**]
Date of Birth: [**2147-9-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8867**]
Addendum:
The patient had two other issues that I failed to include in my
initial hospital course.
*Anemia
The patient was slightly anemic on presentation with a
hematocrit that trended down from 39 to 32 on the day of
discharge. He was guiac negative on rectal exam. This will need
to be rechecked in the outpatient setting.
*Hematuria
A urinalysis checked on the day prior to discharge revealed red
blood cells without sends of pyuria or infection. This was
thought most likely due to resolving foley trauma and the urine
was not grossly bloody. Nevertheless, a follow up UA to
document resolution would be indicated.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8868**] MD [**MD Number(2) 8869**]
Completed by:[**2200-12-2**]
|
[
"728.88",
"348.39",
"425.8",
"707.11",
"293.0",
"V58.66",
"402.90",
"V58.67",
"250.00",
"599.70",
"276.2",
"584.9",
"285.9",
"701.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
18072, 18287
|
7654, 7905
|
332, 396
|
15601, 15625
|
3826, 3885
|
16716, 18049
|
2612, 2630
|
14575, 15339
|
15441, 15580
|
14309, 14552
|
15649, 16693
|
3569, 3807
|
2645, 3269
|
4209, 4727
|
4744, 7631
|
276, 294
|
424, 1908
|
3899, 4195
|
7920, 14283
|
1930, 2235
|
2251, 2596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,512
| 157,068
|
44285
|
Discharge summary
|
report
|
Admission Date: [**2158-6-15**] Discharge Date: [**2158-6-16**]
Date of Birth: [**2093-2-17**] Sex: F
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Patient found unresponsive after falling backwards down stairs.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient was found at bottom of stairs, having fallen backward on
posterior head. Patient was unresponsive. EMS took to OSH where
CXR was performed after intubation before [**Location (un) **] to [**Hospital1 18**].
[**Location (un) **] noted fixed midposition pupils and weak gag. No
collateral history was available. Patient was wearing Holter
monitor when found. She is also know to be taking Lasix.
Patient arrived with interosius line. Given one unit of blood in
ED. Mannitol started prior to transfer.
Past Medical History:
- Patient likely with arrhythmia given Holter
- Possible heart failure given Lasix
- Patient with cirrhosis and ascites based on our imaging
- Other medical history unclear
Social History:
Unknown
Family History:
Unknown
Physical Exam:
On admission:
PHYSICAL EXAM:
Afebrile. BP 110s/50s. HR 96. R 21. 100 O2Sats on pressure
support.
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: unreactive 6 mm, EOMs absent.
Neck: In [**Location (un) 8658**].
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Cool.
Neuro:
Mental status: GCS 4 (eyes fixed open, no speech, extensor
posturing spontaneous and to stimuli, including pain)
Cranial Nerves:
I: Not tested
II: Pupils equally round and non-reactive to light at 6 mm
III, IV, VI: No EOMs. In [**Last Name (LF) 8658**], [**First Name3 (LF) **] doll's not tested. Caloric
not done.
V, VII: No movement.
IX, X: Some gag to tube - weak (reportedly).
[**Doctor First Name 81**]: Flacid
XII: Intubated.
Motor: Reduced bulk. Increased extensor tone, particularly in
right side. Extensor to pain bilaterally, but reuires more
stimulation on right.
Reflexes:
Corneal reflexes absent. Sclera dry. Brisk left biceps and
bilateral patella tendon, but posturing in response to attempts
to ellicit right biceps reflex. Tonic plantar flexion of feet.
Toes upgoing bilaterally
Exam [**6-16**]:
Pupils fixed at 4 and midline. No corneals bilaterally. No mvmt
to BUE to noxious stim; BLE extensor posturing.
Pertinent Results:
[**2158-6-15**] Head CT:
Large L SDH with mass effect on the left hemisphere with
rightward midline
shift and obliteration of suprasellar and most of ambien
cistern, consistent with transtentorial herniation. Concurrent
SAH.
Parasagittal occipital fracture with extension into foramen
magnum
with occipital subgaleal hematoma and subcutaneous emphysema.
Brief Hospital Course:
65F admitted to [**Hospital1 18**] after sustaining a fall and resulting in a
large left SDH and SAH with extensive midline shift.
Neurological exam was poor upon arrival, consis and worsened
later that morning. Pt was kept intubated until family could
arrive. She was extubated at the request of the family and
passed away on [**2158-6-16**] at [**2051**].
Medications on Admission:
Unknown
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural Hematoma
SAH
Parasagittal occipital fracture
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
N/A
Completed by:[**2158-6-16**]
|
[
"571.5",
"801.25",
"789.59",
"E880.9",
"348.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3240, 3249
|
2793, 3153
|
364, 371
|
3347, 3357
|
2413, 2429
|
3413, 3448
|
1147, 1156
|
3211, 3217
|
3270, 3326
|
3179, 3188
|
3381, 3390
|
1200, 1464
|
261, 326
|
399, 909
|
1594, 2394
|
2438, 2770
|
1185, 1185
|
1479, 1578
|
931, 1106
|
1122, 1131
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,836
| 153,406
|
21647
|
Discharge summary
|
report
|
Admission Date: [**2146-9-28**] Discharge Date: [**2146-10-1**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
SSCP
Major Surgical or Invasive Procedure:
1. Cardiac Catheterization.
History of Present Illness:
84 year old woman with history of HTN, hyperlipidemia, CAD s/p
CABG '[**34**] presented to [**Hospital3 2737**] with 6/10 SSCP radiating
to bilateral jaws and left arm. An EKG showed a RBBB, her 1st
set of cardiac enzymes were negative, but she had continued
chest pain ([**6-16**]) after ASA, nitro SLx3, nitro gtt, and heparin
gtt. She was transferred to [**Hospital1 18**] for further care. On
arrival, she was hemodynamically stable without chest pain; her
second set of cardiac enzymes were negative, but she was
nevertheless started on integrillin since she was a high risk
patient. Per her daughter, she had a cath 4mo ago in NJ
reportedly with clean grafts.
ROS was positive for lightheadedness, DOE after walking a few
blocks (unchanged over the past few months), mild nausea (no
vomiting), and tingling in hands.
The patient denied PND, orthopnea, recent weight loss, fatigue,
shortness of breath, palpitations, abdominal pain, change in
bowel or bladder habits. She does note an excoriated, pruritic
rash on her upper back x 1month.
Past Medical History:
1. Hyperlipidemia,
2. HTN,
3. CAD s/p CABG in [**2134**] with LIMA to LAD, SVG to RCA, SVG to
OM1; recent cath [**2146-8-10**] showing patent grafts;
4. ?CRI s/p R renal stent in [**2146-8-10**]
5. Anxiety
6. h/o several admissions in NJ for atypical chest pain per
daughter
Social History:
Patient has recently moved from [**State 760**] to [**Location (un) 86**] in past
month to live near daughter.
Remote tobacco (0.5 ppd x 3 years >20 years ago), denies ETOH,
denies IVDU.
Family History:
Mother and Father with CAD/MI, mother at age 86, father in 60s.
Physical Exam:
VITALS on admission T 97.3, HR 73, BP 109/39, 98% 1L NC
GEN: NAD
HEENT: MMM, OP clear, PERRL
Neck: no JVD
CV: regular S1S2, [**3-12**] HSM at apex, 2/6 SEM at RUSB
Lungs: clear
Abd: soft, non tender, non distended, +BS, no HSM, R groin bruit
Ext: w/wp, no edema, 2+ pulses
Neuro: AOx3
Pertinent Results:
Cardiac Enzymes
First set at OSH on [**9-28**] PM negative.
[**2146-9-28**] 09:32PM CK(CPK)-39
[**2146-9-28**] 09:32PM CK-MB-NotDone cTropnT-<0.01
[**2146-9-29**] 1pm CK 34, MB 5, TnT <0.01
CXR ([**9-28**]):
IMPRESSION: Areas of pleural calcification and biapical
scarring. No pneumonia or pneumothorax.
ECHO ([**9-29**]):
Conclusions:
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 root is mildly dilated.
The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve
stenosis. Mild to moderate ([**1-7**]+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no
pericardial effusion.
Cardiac Cath ([**9-29**]):
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 100
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 50
7) MID-LAD DISCRETE 70
8) DISTAL LAD DIFFUSELY DISEASED 40
10) DIAGONAL-2 DISCRETE 50
12) PROXIMAL CX DISCRETE 50
14) OBTUSE MARGINAL-1 DISCRETE 100
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 NORMAL
29) SVBG #2 NORMAL
32) LIMA NORMAL
COMMENTS:
1. Selective coronary angiography revealed a right-dominant
system
with three vessel coronary artery disease and patent bypass
grafts. The
LMCA showed no angiographically apparent flow-limiting lesions.
The LAD
had moderate proximal disease with a 50% lesion at the second
diagonal
branch and a 70% mid vessel lesion with the distal small and
diffusely
diseased vessel filling via the LIMA. The LCX had 40 to 50%
ostial
disease with an FFR of 0.94 by pressure wire with iv adenosine
(not a
signicant lesion) and an occluded OM branch filling via a patent
SVG.
The RCA had a proximal occlusion with the distal vessel filling
via a
patent SVG.
2. Limited resting hemodynamics showed normal central aortic
pressures.
3. Left ventriculography was deferred.
4. The right femoral arteriotomy was closed with a perclose
device.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Right femoral arteriotomy closed with perclose device.
Brief Hospital Course:
1. Coronary Artery Disease - The patient has a history of CAD
s/p CABG in [**2134**] in [**Doctor First Name 5256**] with LIMA to LAD, SVG to RCA,
SVG to OM1. She initially presented on [**9-28**] to an OSH with chest
pain, was started on heparin and nitro drips. Her blood
pressure fell and was transferred to [**Hospital1 18**] for further
management. On arrival she was chest pain free and
hemodynamically stable; she was started on integrillin. Her
aspirin and statin were continued per her outpatient doses. The
patient's cardiac enzymes were cycled and were negative x3. The
patient's outpatient cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 56961**])
was contact[**Name (NI) **] and sent over the [**2146-8-10**] cath report as well as an
old EKG. The hospital where the CABG was done was also
contact[**Name (NI) **] but was unable to provide any information
([**Telephone/Fax (1) 56962**]). The following morning ([**9-29**]) the patient
complained of chest pain and lightheadedness, an EKG showed
concordance in lead V2, but otherwise an unchanged [**Location (un) 1131**] from
prior EKGs done during admission. Another set of cardiac
enzymes was negative. The patient was given IV morphine, IV
nitro, and 0.5mg ativan with good effect. The EKG change was
thought to be due to lead placement. However, given these
symptoms in a patient with known CAD, she was taken to cath --
there she was found to have native 3VD but fully patent grafts.
After cath, the patient remained chest pain free and felt well.
Her drips were titrated off. She was discharged home on all her
previous cardiac medications as well as plavix 75mg daily.
2. PUMP: The patient had an ECHO on [**9-29**] which found a preserved
EF of 55%, no LV or RV wall motion abnormalities, [**1-7**]+ AI, mild
aortic root and ascending aortic dilation. On the AM of
[**2146-9-30**], the patient was given enalapril 25mg po with a drop in
her blood pressure to SBP in the 50-60s. She was given some NS
IVF, observed overnight, and discharged the following day on
enalapril 2.5mg po qd.
3. Rhythm: RBBB on EKG, an EKG was obtained from the patient's
cardiologist in [**State 760**] which showed that the bundle was old.
The patient remained in NSR during admission.
4. Hyperlipidemia: The patient's outpatient lipitor was
continued during this admission.
5. Hypertension: The patient was continued on her outpatient
metoprolol 25mg [**Hospital1 **]. Her enalapril was held given that her
creatinine was 1.3, but she was restarted on it on [**9-30**] - the
day of discharge - as her creatinine was 0.8. She was also
restarted on her HCTZ on [**9-30**].
6. Respiratory: stable oxygen saturations during admission. Not
requiring supplemental oxygen on discharge.
7. Renal: The patient is s/p a R renal stent in [**8-10**]. She came
in with a creatinine in the low 1s - this trended down during
admission. The patient was hydrated and given mucomyst
peri-cath. Her creatinine on discharge was 0.8.
8. GI: The patient tolerated an oral cardiac diet during
admission - this was held prior to cath.
9. Heme: Hematocrit was stable during admission as were
platelets. The heparin was stopped after catheterization as was
the integrillin.
10. Prophylaxis: the patient was seen by PT and was able to
ambulate before discharge; they will see her for home PT. She
was tolerating an oral diet and maintained on a bowel regimen.
11. Communication: the patient's daughter, [**Name (NI) **], was updated
about her progress throughout her admission.
12. She was discharged home with services to follow up with her
new primary care physician.
Medications on Admission:
Aspirin 81
Enalapril 2.5
Lipitor 20
Metoprolol 25 [**Hospital1 **]
HCTZ 25
Alprazolam 0.25mg q6hrs prn
nitro prn
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. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Enalapril Maleate 2.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Anxiety
2. CRI
3. HTN
4. CAD s/p CABG with patent grafts
Discharge Condition:
Ambulatory, tolerating an oral diet, stable on room air.
Discharge Instructions:
Please take all of your medications as instructed. Please [**Name8 (MD) 138**]
MD for any chest pain/tightness, shortness of breath, or for any
other concerns.
Followup Instructions:
Please call your new PCP for [**Name9 (PRE) 702**] appointment within [**1-7**]
weeks. If you would like a primary care physician at [**Hospital1 1535**], please call [**Telephone/Fax (1) 250**].
|
[
"V45.81",
"424.0",
"593.9",
"V15.82",
"401.9",
"414.01",
"272.4",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.20",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9528, 9583
|
4943, 8625
|
287, 317
|
9687, 9745
|
2300, 4802
|
9953, 10153
|
1915, 1980
|
8788, 9505
|
9604, 9666
|
8651, 8765
|
4819, 4920
|
9769, 9930
|
1995, 2281
|
243, 249
|
345, 1396
|
1418, 1695
|
1711, 1899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,417
| 101,256
|
24209+24210
|
Discharge summary
|
report+report
|
Admission Date: [**2153-6-14**] Discharge Date: [**2153-7-24**]
Date of Birth: [**2114-4-24**] Sex: M
Service: [**Last Name (un) 7081**]
ADDENDUM: The patient is currently on postoperative day 38.
He has been preparing for discharge to rehabilitation for the
past several days and it was decided that the patient was
stable and ready to be discharged on this day. At the time of
this dictation, the patient's physical examination is as
follows - temperature is 96.9, heart rate 94, sinus rhythm,
blood pressure 133/60, respiratory rate 23, O2 saturation 97%
on a 50% tracheostomy mask. The patient's lab data on the day
of discharge reveals a white count of 8.9, hematocrit 30.3,
platelets 478, INR 1.1, sodium 140, potassium 4.0, chloride
104, CO2 of 29, BUN 13, creatinine 0.4, glucose 118.
PHYSICAL EXAMINATION: He is alert and oriented in responses.
He moves all extremities and follows commands with a nonfocal
exam. Respiratory - breath sounds are somewhat diminished
although clear bilaterally. He has a strong productive cough.
GI - PEG feeding tube is intact and his abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well-perfused with no edema.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Status post ascending aortic dissection repair with a No.
28 Gelweave graft. Also, status post aortic valve
replacement with a No. 25 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial
valve.
2. Status post tracheostomy.
3. Status post PEG.
4. Status post respiratory failure.
5. Status post postoperative atrial fibrillation.
6. Status post PICC placement.
7. Asthma.
8. GERD.
FOLLOW UP: The patient is to have follow-up with Dr.
[**Last Name (STitle) 70**] in 6 weeks.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily, Flovent 2 puffs
b.i.d., albuterol 2 puffs q.4h., Atrovent 2 puffs q.6h.,
lansoprazole 30 mg daily, Norvasc 10 mg daily, labetalol 200
mg b.i.d., heparin 5000 units t.i.d., amiodarone 400 mg daily
x7 days, then 200 mg daily x1 month, Lasix 20 mg daily.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2153-7-24**] 10:54:03
T: [**2153-7-24**] 11:12:05
Job#: [**Job Number 61481**]
Admission Date: [**2153-6-14**] Discharge Date: [**2153-7-24**]
Date of Birth: [**2114-4-24**] Sex: M
Service: [**Last Name (un) 7081**]
CHIEF COMPLAINT: Aortic dissection.
HISTORY OF PRESENT ILLNESS: This is a 39 year old man with
the sudden onset of mediastinal pain. No prior history of
pain or cardiac problems. [**Name (NI) **] presented to an outside
hospital, where a CAT scan showed a type A dissection. The
patient was then transferred emergently to the [**Hospital **] [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **].
PAST MEDICAL HISTORY: Significant only for asthma and GERD.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Meds at home include Combivent and occasional
Prilosec.
ALLERGIES: no known drug allergies.
SOCIAL HISTORY: No tobacco use. Occasional alcohol use.
PHYSICAL EXAMINATION: Vital Signs: Heart rate 62. Blood
pressure 110/54. Respiratory rate 20. General: No acute
distress. HEENT: Sclerae icteric. Conjunctivae non-injected.
Mucous membranes moist. Neck is supple with no
lymphadenopathy. Lungs clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm with 3/6 murmur at
the right sternal border. Pulses are symmetrical bilaterally.
Abdomen is soft and nontender and nondistended. Extremities:
Warm and well perfused with no cyanosis, clubbing or edema.
Neuro: Alert and oriented x3. Moves all extremities. Nonfocal
exam.
LABORATORY DATA: Sodium 140, potassium 4.4, chloride 106,
CO2 26, BUN 14, creatinine 1.4, glucose 109, albumin 3.4.
White count 5.4, hematocrit 39, platelets 278.
Chest CT with ascending aortic dissection through the arch to
the abdominal aorta. No pericardial effusion.
HOSPITAL COURSE: The patient was brought emergently to the
operating room. Please see the OR report for full details. In
summary, he had an emergent ascending aorta repair with a #28
sidearm Gelweave graft, as well as an AVR with a #25
[**Last Name (un) 3843**]-[**Doctor First Name 7624**] pericardial valve. His bypass time was
158 minutes with a cross clamp time of 124 minutes, and circ
arrest of 16 minutes. He tolerated the operation well and was
transferred to the cardiothoracic intensive care unit. At the
time of transfer he was in a sinus rhythm at 100 beats per
minute. He had propofol infusion at 20 mics per kilogram per
minute and nitroglycerin at 1.5 mics per kilogram per minute.
In the immediate postoperative period, the patient remained
hemodynamically stable. However, he had a fair amount of
bleeding and required several transfusions of packed red
blood cells, as well as fresh frozen plasma. The patient also
had difficulty with ventilation. An initial attempt to awaken
the patient, his O2 sats dropped into the 80's. Following
several recuperative breaths, the patient was re-sedated and
chemically paralyzed. Over the next several days the patient
continued to experience difficulty with ventilation. By chest
x-ray it appeared that he had early onset ARDS. A pulmonary
consult was called.
Additionally the patient suffered from persistent fevers, for
which he was pan cultured on numerous occasions. Infectious
disease consult was also called. Eventually the patient grew
methicillin sensitive staph from his sputum and was treated
with appropriate antibiotics.
From a respiratory standpoint the patient remained paralyzed
and sedated and fully ventilated. He had numerous
bronchoscopies.
Over the next week or so, the patient made slow progress from
a pulmonary standpoint, to the point where the paralytics
were to be discontinued. However, every attempt to turn down
his sedation and remove the paralytics was met with increased
hypoxia, as well as acidosis requiring reinstitution of these
measures. During this entire period the patient was
undergoing bronchoscopy on an every other day basis.
On postoperative day 9 the patient was noted to have
bilateral pleural effusions. A right thoracentesis was
performed on that day and drained about 600 cc of
serosanguineous fluid. Later in the day the patient became
hemodynamically unstable. A chest x-ray revealed a left-sided
pneumothorax. Bilateral chest tubes were placed and a Swan-
Ganz catheter was also placed. Additionally following the
placement of the Swan-Ganz catheter, the patient appeared to
be septic and his antibiotic coverage was broadened.
The patient recovered from this setback, and by postoperative
day 14 the patient's paralytics were discontinued. He did,
however, continue to require full ventilation and was sedated
with morphine and Ativan, which were slowly weaned over the
next several days.
Over the course of the next week, the patient continued to
make progress with his vent wean, until postoperative day 24,
when the patient was strictly on pressure support, he
developed a mucous plug, then became bradycardic and
ultimately had a short period of asystole. With aggressive
pulmonary toilet, as well as bag ventilation, the patient
recovered from this episode. An EP consult was called. They
saw no need for a temporary or permanent pacemaker at this
point. However, thoracic surgery was also consulted and a
trache and PEG were placed on postoperative day 25, following
which the patient had an episode of atrial fibrillation, from
which he was DC cardioverted into a sinus rhythm. Following
trache and PEG placement, the patient continued to make
progress with his pressure support weaned, and by
postoperative day 30 he was having trache mask trials. By
postoperative day 33 he was on strictly trache mask. At the
time of this dictation the patient has been on trache call
for approximately 5 days without requiring any ventilatory
support.
DICTATION ENDS HERE
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2153-7-24**] 10:40:57
T: [**2153-7-24**] 11:50:24
Job#: [**Job Number 61482**]
|
[
"933.1",
"286.6",
"424.1",
"530.81",
"482.41",
"427.5",
"441.01",
"707.03",
"512.1",
"401.9",
"708.3",
"511.9",
"427.31",
"518.5",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.6",
"34.91",
"38.45",
"35.21",
"44.32",
"88.72",
"34.04",
"31.1",
"33.24",
"89.64",
"39.61",
"99.15",
"35.39",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
1280, 1683
|
1802, 2506
|
4064, 8304
|
3008, 3124
|
1695, 1778
|
3205, 4046
|
2524, 2544
|
2573, 2922
|
2945, 2984
|
3141, 3182
|
1252, 1259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,999
| 165,095
|
10488
|
Discharge summary
|
report
|
Admission Date: [**2185-5-7**] Discharge Date: [**2185-5-17**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Abdominal pains, BRBPR
Major Surgical or Invasive Procedure:
Colonscopy done [**2185-5-11**]
History of Present Illness:
The patient is an 89 year old female with a history of stroke,
seizures, vascular dementia, hypertension, hyperlipidemia, and
CAD who presented with complaints of abdominal pain, BRBPR and
loose stools x 1 week. Patient had a colonoscopy [**2185-4-29**] as part
of an evaluaton for anemia which showed grade 1 internal
hemorrhoids, a polyp that was removed via polypectomy and a
cecal angioectesia that was treated via thermal therapy.
.
The patient is a poor historian, but from transfer records and
ED sign out, she had been having worsening abdominal pain for
the last week. She had concurrently developed frequent loose
stools that were particularly malodorous. Labs were checked at
her nursing home, which showed an elevated WBC of 16. Due to
concerns for C.difficile empiric Flagyl was started. On the
morning of her ED presentation the patient had a a bloody bowel
movement with several large maroon colored whole blood clots
that were passed. She denied lightheadedness, chest pain,
palpitations. Records show recent low grade temperatures as
well. The patient was transferred to [**Hospital1 18**] for further
evaluation. Review of systems was otherwise negative.
.
On presentation to [**Hospital1 18**], HR 96.8, BP 163/114, HR 89, 99% on RA.
The patient was noted to have BRB per rectum on exam. A CT scan
was obtained which initially was read as only having
diverticulosis. The patient spiked a temperature of 102F at one
point but then had fairly normal temperatures. A chest x-ray
showed a question of a retrocardiac opacity, so the patient was
given levofloxacin/vancomycin in ED for PNA coverage. Later, and
updated read of the CT-abdomen questioned possible small
diverticultis, and Flagyl was added. The patient's hematocrit
was stable from baseline. She was admitted to medicine for
further management.
.
Past Medical History:
# Syncope since [**2179**]: per neuro note [**5-3**], these occur while
sitting in church, at a funeral, and eating.
-- [**10-29**]: Holter with frequent atrial ectopic beats and short
bursts of atrial tachycardia
-- [**10-29**]: Echo: mild symmetric LVH. EF normal. No AS, mild MR
-- [**10-31**]: EEG: No focal, lateralizing, or epileptiform features
were seen.
-- [**12-31**]: MRI: Extensive roughly symmetric T2 hyperintensity in
the cerebral white matter and pons with extension into the
temporal horns
# Hypertension
# Hyperlipidemia
# Vascular Dementia
# Ptosis - workup to date includes negative myasthenia
antibodies, normal EMGs. Dr. [**Last Name (STitle) **] of neurology couldn't
fully exclude ocular myasthenia (unlikely though). S/P bilateral
repair w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7363**] of ophthalmology for dermatochalsis of
the upper lids
# Glaucoma
# Stroke by CT
.
Social History:
Ms. [**Known lastname 34601**] lives at an [**Hospital3 **] center in an apartment.
Elderly sister, niece, and grand nephew live nearby. She denies
tobacco, alcohol, or any history of any illicit drug use.
Family History:
Noncontributory
Physical Exam:
INITIAL PHYSICAL EXAM
Vitals: T: 97.4 BP: 120/60 HR: 60 RR: 18 O2: 100% RA
Eyes: EOMI, PERRL, conjunctiva clear, mildly injected
bilaterally, anicteric, no exudate, ptosis right>left
ENT: Dry MM
Neck: No JVD, no LAD, no thyromegaly, no carotid bruits
Cardiovascular: RRR, nl S1/S2, no m/r/g
Respiratory: CTA bilaterally, comfortable, no wheezing, no
ronchi, no rales
Gastrointestinal: soft, midly distended, mildly tender in lower
abdomen, no hepatosplenomegaly, normal bowel sounds
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint
swelling, trace edema in the bilateral extremities
Neurological: Alert and oriented x3, dysarthric speech but
fluent, sensation WNL, CNII-XII intact except for right
nasolabial fold flattening and right ptosis greater than left;
unable to fully cooperate with strength exam despite redirection
but has 4-5/5 strength in all extremities with 4-/5 in right
upper extremity
.
.
PHYSICAL EXAM AT TIME OF TRANSFER OUT OF MICU TO MEDICAL FLOOR:
Vitals: T 99.4F, HR94, BP142/61, RR 18, O2 Saturation was 99% on
RA.
General: A&Ox3, no apparent distress, sitting up in bedside
chair wrapped in blanket.
HEENT: PERRL, EOMI, MMM, OP clear, nonicteric sclera
Neck: JVP at 9cm, no LAD, no thyromegaly, 2+ carotid upstrokes,
no bruits noted
Cardiac: RRR, S1/S2 appreciated, mild systolic murmur at at RUSB
(II/VI)
Resp: CTA bilaterally, no wheezes or rhonchi
Abd: normoactive BS, soft, midly distended, nontender to
palpation
Ext: No edema noted, distorted gastrocnemius contour bilaterally
noted, 2+ pedal pulses bilaterally
Neuro: CNs [**3-10**] grossly in tact, no gross sensory deficits,
motor test limited due to apparent weakness that was bilateral
at lower extremities [**5-1**] B/L. Upper extremities with no gross
motor deficits.
Skin: multiple small moles and skin tags over her neck and upper
torso, no lesions, open sores or rashes noted.
Pertinent Results:
ADMISSION LABS:
[**2185-5-7**] 04:09PM LACTATE-1.5
[**2185-5-7**] 01:42PM HGB-11.6* calcHCT-35
[**2185-5-7**] 01:30PM GLUCOSE-139* UREA N-26* CREAT-0.8 SODIUM-142
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
[**2185-5-7**] 01:30PM ALT(SGPT)-11 AST(SGOT)-13 ALK PHOS-87 TOT
BILI-0.2
[**2185-5-7**] 01:30PM LIPASE-53
[**2185-5-7**] 01:30PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.9
[**2185-5-7**] 01:30PM WBC-16.6*# RBC-3.42* HGB-10.8* HCT-32.8*
MCV-96 MCH-31.6 MCHC-32.8 RDW-14.2, PLTS 227
[**2185-5-7**] 01:30PM NEUTS-88.8* LYMPHS-5.6* MONOS-4.7 EOS-0.9
BASOS-0
[**2185-5-7**] 01:30PM PT-14.1* PTT-32.7 INR(PT)-1.2*
.
URINE STUDIES:
[**2185-5-7**] 04:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.049*
[**2185-5-7**] 04:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2185-5-7**] 04:55PM URINE RBC-[**3-31**]* WBC-[**7-6**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
.
MICROBIOLOGY STUDIES:
.
[**5-7**] URINE Culture //**FINAL REPORT [**2185-5-9**]**
URINE CULTURE (Final [**2185-5-9**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
BLOOD CULTURES 4/11, [**5-8**], [**5-10**] - NEGATIVE
BLOOD CULTURES 4/17 -PENDING , NO GROWTH TO DATE
[**5-8**] and [**5-14**] :
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2185-5-15**]):
Feces negative for C.difficile toxin A & B by EIA.
.
ADDITIONAL REPORTS AND IMAGING:
.
[**5-7**] EKG: HR 108, Sinus tachycardia with ventricular premature
beats. Leftward axis. Possible left ventricular hypertrophy.
Non-specific ST-T wave abnormalities.
.
[**5-7**] CT ABD AND PELVIS:
IMPRESSION:
1. Severe sigmoid and descending colonic diverticulosis with
mild
diverticulitis. Recent colonoscopy showed no masses.
2. Multiple fibroids with several degenerating fibroids with
large right
complex exophytic fibroid. Anterior fiborid appears necrotic,
however,
maligancy cannot be excluded and Gynecologic evaluation for
surgical
management is recommended. If no surgery is performed,
short-term follow-up in [**7-4**] weeks is recommended with MRI or CT.
3. Right adnexal mass which has features consistent with a
complex dermoid. Gynecologic evaluation for surgical management
is recommended. Heterogeneous mass adjacent to the right border
of the uterus, is likely a uterine fibroid. The left adnexa is
not clearly identified.
4. No evidence for ischemic colitis. No bowel obstruction or
dilation. Fat-
containing ventral hernia.
5. Bilateral adrenal calcifications, which may be due to
granulomatous
disease or remote hemorrhage
.
[**5-7**] CXR -
There are persistent low lung volumes. Opacity in the left lower
lobe is
likely atelectasis. Atelectasis in the right base is unchanged.
Cardiomediastinal contours are unchanged. Cardiac size is top
normal. There is no pneumothorax or enlarging pleural effusions.
No other interval change.
.
[**5-13**] CXR -
There are low lung volumes. Subsegmental atelectasis are in the
left base.
There is no pleural effusion or pneumothorax. Moderate
cardiomegaly is
stable. No CHF. Moderate degenerative changes are in the
thoracic spine.
.
[**5-15**] REPEAT CT ABDOMEN:
IMPRESSION:
1. Overall no significant change.
2. Mild sigmoid diverticulitis.
3. Fat-containing mass anterior to the right psoas muscle. This
likely
represents a teratoma originating from the right ovary. A
retroperitoneal
liposarcoma is also possible but less likely.
4. Two additional large mixed-attenuation pelvic masses, one
exophytic from
the uterus the other one likely an enlarged internal iliac lymph
node.
findings are concerning for malignancy such as leiomyoscarcoma
with lymph
node metastases.
5. Small fat-containing umbilical hernia.
6. Prominent right pulmonary artery, suggesting pulmonary
arterial
hypertension.
.
DISCHARGE LABS:
[**2185-5-17**] 06:50AM BLOOD WBC-18.0* RBC-3.33* Hgb-9.6* Hct-29.8*
MCV-89 MCH-29.0 MCHC-32.4 RDW-15.3 Plt Ct-496*
[**2185-5-17**] 06:50AM BLOOD Plt Ct-496*
[**2185-5-17**] 06:50AM BLOOD Glucose-98 UreaN-6 Creat-0.6 Na-145 K-3.7
Cl-105 HCO3-33* AnGap-11
[**2185-5-17**] 06:50AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.8
Brief Hospital Course:
.
#Rectal bleeding: Ms. [**Known lastname 34601**] was admitted with complaints of 2
days of bright red blood per rectum and initially had a stable
hematocrit in the 28-32 range. After several large bloody
stools/clots passed on [**4-25**] she had Hct drop to 21 which
prompted MICU transfer. She then needed 5 total units blood and
3+ liters of IVFs to correct her hypotension which reached a
nadir of 50/palpation. She was monitored closely in the ICU and
her hematocrit recovered to 28-30 range again where she has
remained since that time. After transfer back to the general
medical floor she also remained hemodynamically stable and her
abdominal pains and diarrhea tapered off and completely abated
by time of discharge. No complaints of any emesis during her
hospital course but she experienced some nausea on the day she
was sent to the ICU. GI team followed her closely in the
inpatient setting and performed a STAT colonoscopy on [**5-11**] when
she had marked increase in her lower GI bleeding but there was
no clear bleeding source; severe diverticulosis and grade 2
internal hemorrhoids were noted. There was very little bleeding
above the level of the cecum during scope procedure so the GI
service felt she did not have any upper GI sources. Possible
bleed sites were perhaps from her recent polypectomy or her
known cecal angioectasia sites/AVMs. Polypectomy and thermal
treatment to her angioectasias in cecum done the first week in
[**Month (only) 547**] just prior to her complaints of bleeding so the timeline
certainly favors a re-bleed from one of these sites. Blood
pressure medications were all held and she was initially placed
on [**Hospital1 **] IV Protonix which was later switched to PO q-daily PPI
and at discharge she can return to her usual home omeprazole
therapy. Hematocrits were intially checked q6-8 hours, then
spaced to q12 hours and then qdaily as she had no signs of
re-bleeding for days and her hematocrit has remained stable.
Team has been holding usual Plavix therapy for her CVA history
due to GI bleeding. Patient allergic to aspirin so she had not
been placed on any aspirin for her CVAs. She will plan to
follow-up with her PCP regarding timing of restarting her
Plavix. Through her hospital course she was advanced from NPO to
clear fluids and then to a regular PO diet which she has been
tolerating very well for several days now leading up to
discharge. At time of discharge she was asked to follow-up with
[**Hospital1 18**] outpatient gastroenterology appointment.
.
# Hypotension: Ms. [**Known lastname 34601**] has now fully recovered from a brief
drop in her blood pressures in the acute setting of her GI bleed
earlier in her hospital course. She
had a drop to 50/palp on medical floor [**5-10**] but recovered after
IVFs and 5 additional units of blood were given. Most likely
hypovolemic related drop from blood loss but she had a
persistent leukocytosis concerning for inflammatory
contributions to her hypotension as well, SIRS/sepsis etiology
was in the differential initially but despite multiple tests and
antibiotics she continued to have an elevated WBC and given the
chronic course of her leukocytosis and all of her negative blood
cultures it seemed much more likely that her BP drop was
secondary to volume losses with GI bleeding vs. any infections.
.
.
#Leukocytosis: Ms. [**Known lastname 34601**] had an isolated fever in the ED to
102F and a WBC count of 16 with a left shift noted at time of
her admission. Fevers tapered and she had no more significant
bouts of any elevated temperatures during her hospital course.
At her outside facility she had been started on some Flagyl just
prior to transfer to ED per reports due to some initial concerns
for C.difficile as she was having some abdominal pains and loose
stools with her lower GI bleeding. She was placed on a few days
of oral Vancomycin alongside IV Flagyl briefly but after two C.
difficile stool studies returned negative these were stopped.
She was continued on PO Flagyl however after a CT done [**5-7**]
noted some area that was consistent with mild diverticulitis.
Soon after her GI bleeding stopped she had no more diarrhea and
no abdominal cramps or pains. After repeat CT Abdomen done [**5-15**]
showed again mild diverticulitis she was started on a 7 day
course of Ciprofloxacin and Flagyl, her last day should be
[**2185-5-23**]. Initial diarrhea was probably from combination of her
diverticulitis and added cathartic effects of GI bleeding. There
was a lengthy workup for her persistent elevated WBC count
which stayed in 16-20 range during her hospital course. PNA was
essentially ruled out as she had no cough or oxygen requirement
and repeated CXRs showed no opacities. A positive E.Coli UTI was
discovered for which she was given IV Ceftriaxone x 7 days;
completed on [**2185-5-16**]. She has no residual dysuria complaints or
suprapubic tenderness at time of discharge today. Leukocytosis
continued despite adequate treatment of her UTI so she likely
has another underlying insult or etiology behind elevated WBCs.
She has a borderline stage I-II debubitis lesion at sacral area
but there are no deep wounds to promote such an elevated WBC
level. CT Abdomen/pelvis had also revealed some necrotic, older
fibroids which may be promoting WBC elevations. OB/Gynecology
team was consulted and felt that her fibroids would not create
such an elevated leukocytosis however. Final CT abdomen read on
repeat imaging done [**5-15**] showed a fat-containing mass anterior
to the right psoas muscle. This was possibly a teratoma
originating from the right ovary or a potential retroperitoneal
liposarcoma as well. Malignancy is in the differential,
particulary given some prominence of iliac lymph nodes. PCP made
aware of this finding and a follow-up Ob/Gyn appointment was
made with Dr. [**Last Name (STitle) 34602**] here at [**Hospital1 18**]. Clinically, she seemed very
stable with no complaints by time of discharge.
Infectious workup to explain her elevated WBC count was largely
unrevealing. The most likely explanation to date is
diverticulitis on both abdominal CTs. Therefore she was
continued on a 7 day course of Cipro/Flagyl at discharge.
.
#Hypertension: Initially she had low to normotensive blood
pressures and as above she became hypotensive in setting of GI
bleeding so her usual HCTZ BP medication were held. By time of
discharge she had rising BPs to systolic ranges of 150-160s at
times so she was placed back on her usual home 12.5mg daily
HCTZ.
.
#Pelvic Mass: CT noted multiple degenerating fibroids with
exophytic necrotic characteristics which were concerning.
Retroperitoneal malignancy such as liposarcoma questioned given
some prominent iliac lymph nodes and location of mass. Right
adnexal mass had features most consistent with a complex dermoid
or teratoma however. Gynecology team was consulted and felt
there were no indications for any immediate surgeries. Per
patient, no prior post-menopausal bleeding. Follow-up pelvic US
done and also confirmed right adnexal mass and fibroids as
above. She needs follow-up imaging in [**7-4**] weeks with MRI or CT
along with a gynecology outpatient follow-up which has been
arranged for early [**Month (only) **] with Dr. [**Last Name (STitle) 34602**].
.
#Urinary Tract Infection: As above, she had an E.Coli UTI during
this hospital stay which was treated for 7 days with IV
Ceftriaxone, therapy ended on [**5-16**] and she has had no additional
complaints of frequency , dysuria or suprapubic tenderness on
exam.
.
#. Hyperlipidemia: She was continued on her usual 80mg of daily
Zocor therapy. Given allergy to aspirin and her bleeding this
medication is contraindicated.
.
#.Glaucoma: Longstanding issue, no new vision changes per
patient on this admission. She was continued on her usual
Travoprost, Timolol Maleate drops and Latanoprost.
.
#. CVA history: Per records, neurology notes state microinfarcts
in the past with associated dementia. In survey of prior
CTs/MRIs unable to find any reports of any other overt large
scale CVAs otherwise. Team continued holding Plavix due to GI
bleeding concerns. She will discuss when to restart this
medication with PCP at [**Name9 (PRE) 702**].
.
#. Seizure Disorder: No recent breakthrough seizures; stable.
She was continued on her usual Keppra therapy daily.
.
#Fluids, Electrolytes and Nutrition: Advanced diet slowly from
NPO to clear liquids and then to regular diet which she has been
tolerating well. Monitored and repleted electrolytes as needed.
.
#Prophylaxis: Ms. [**Known lastname 34601**] was continue on daily PPI and
pneumoboots placed for DVT prevention. She was also seen by
physical therapy to help her attempt ambulation and do
occasional exercises and get out of bed and into the bedside
chair. Ambulation still quite limited and she needs assistance
with walker as was the case just prior to admission with her
usual baseline.
.
#Code Status: She was maintained as a full code status for the
entirety of her hospital course and this was confirmed with the
patient.
.
Medications on Admission:
Plavix 75mg daily
Fexofenadine 60mg daily
Xalatan OU daily
Kepra 1g [**Hospital1 **]
Omeprazole 20mg daily
Zocor 80mg daily
Timolol Maleate 0.5% OU qam
Travoprost 0.004% OU qhs
Calcium+ Vit D3
Vitamin D2
Bisacodyl
MVI
HCTZ 12.5mg daily
Discharge Medications:
1. [**Doctor First Name **] 60 mg Tablet [**Doctor First Name **]: One (1) Tablet PO once a day.
2. Levetiracetam 250 mg Tablet [**Doctor First Name **]: Four (4) Tablet PO BID (2
times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Doctor First Name **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Xalatan 0.005 % Drops [**Doctor First Name **]: One (1) Ophthalmic once a day:
apply to both eyes one daily .
5. Simvastatin 40 mg Tablet [**Doctor First Name **]: Two (2) Tablet PO DAILY
(Daily).
6. Timolol Maleate 0.5 % Drops [**Doctor First Name **]: One (1) Drop Ophthalmic
DAILY (Daily).
7. Travoprost 0.004 % Drops [**Doctor First Name **]: One (1) Ophthalmic qhs ().
8. Calcium Carbonate 500 mg Tablet, Chewable [**Doctor First Name **]: One (1)
Tablet, Chewable PO BID ().
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Doctor First Name **]: One (1)
Tablet PO DAILY (Daily).
10. Multivitamin Capsule [**Doctor First Name **]: One (1) Capsule PO once a day.
11. Hydrochlorothiazide 12.5 mg Capsule [**Doctor First Name **]: One (1) Capsule PO
DAILY (Daily).
12. Ciprofloxacin 500 mg Tablet [**Doctor First Name **]: One (1) Tablet PO twice a
day for 7 days.
13. Flagyl 500 mg Tablet [**Doctor First Name **]: One (1) Tablet PO three times a
day for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
#Lower gastrointestinal bleeding
#Urinary Tract Infection
.
Secondary:
# Prior Syncopal episodes since [**2179**]
# Hypertension
# Hyperlipidemia
# Vascular Dementia
# Ptosis -
# Glaucoma
# Stroke by CT
Discharge Condition:
Clinically stable. Fully alert and oriented. No apparent
distress.
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**].
.
You were admitted after noticing bleeding from your rectum and
abdominal pains. You had worsening bleeding that caused some
drop in your blood pressures and you needed blood transfusions
and IVFs to stabilize your blood pressure. You were sent to the
intensive care unit for a few days for closer monitoring. The
gastrointestinal team was called and you underwent a colonoscopy
which was unable to show the exact source of your bleeding
although the team felt it was from a lower abdominal source.
Fortunately, you stopped bleeding and your blood cell counts
stabilized.
.
You were also found to have a urinary tract infection during
your hospitalization and you were treated with 7 days of IV
antibiotics.
.
You had some peristent elevations in some white blood cell
counts that need to be followed up with your primary care
physician after discharge. Several lab studies were done and
imaging studies were done to try to find specific reasons for
your high white blood cell counts but were normal. Clinically
you were feeling much better by time of discharge and the
medical team was comfortable having you follow-up closely with
your PCP as an outpatient.
.
MEDICATION INSTRUCTIONS:
-Please continue to hold Plavix for now given your recent GI
bleeding, follow-up with your PCP regarding when to restart this
medication at a later date
-Hold your usual Bisacodyl for now given your recent loose
stools; discuss restart date with your PCP
[**Name9 (PRE) 15282**] to take a full 7 day course of Cipro/Flagyl for your
diverticulitis therapy
-Otherwise, please continue your usual home medication regimen
as outlined below.
.
Lastly, if you have any additional fevers, chills, burning with
urination, bloody urine, diarrhea, bleeding per rectum, bloody
stools, constipation, chest pains, fainting, dizziness or any
other acute health concerns please contact your primary doctor
or return to the emergency room.
.
Followup Instructions:
.
1) You were set up for a follow-up with your primary care M.D.,
Dr. [**Last Name (STitle) **] for 5pm on [**2185-5-17**] when you return to the [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **].
.
2) You were set up for a follow-up with OB/Gyn on the [**Location (un) **]
of the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**] [**Hospital1 18**] with Dr.
[**Last Name (STitle) 34602**]. Phone:[**Telephone/Fax (1) 2664**]
.
3) Please call #([**Telephone/Fax (1) 2233**] in the next week to set up an
outpatient gastroenterology appointment here at [**Hospital1 18**] over the
next 6 weeks time.
.
**You should have a repeat CBC in 1 week to follow your white
blood cell count.
Completed by:[**2185-5-17**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
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237, 270
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21042, 21111
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5250, 5250
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5266, 9675
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3088, 3295
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,123
| 102,667
|
7937+55895
|
Discharge summary
|
report+addendum
|
Admission Date: [**2186-5-16**] Discharge Date: [**2186-5-23**]
Date of Birth: [**2118-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2186-5-19**] Coronary Artery Bypas Graft x 5 (Left internal mammary to
left anterior descending, Saphenous vein graft to diagonal,
Saphenous vein graft to Ramus, Saphenous vein graft to Obtuse
marginal, Saphenous vein graft to left posterior descending
artery)
[**2186-5-16**] Cardiac Cath with IABP insertion
History of Present Illness:
67 yo DM with history of type 2 diabetes, coronary disease,
status post renal transplant, sciatica, atrial fibrillation, and
chronic renal insufficiency and previous DES in the LAD presents
with CP and STEMI. Pt had a cardiac cath with reopening of LAD.
He has 60% LM and 3 vessel CAD and had IABP placed at the cath
lab.
Past Medical History:
Coronary Artery Disease, s/p Non-ST Elevation Myocardial
Infartcion, s/p atherectomy LAD in [**2176**], s/p 2.5 x 13 mm
Cypher DES to mid LAD in [**6-/2180**], s/p 2.75 x 28 mm Taxus DES for
ISR in [**5-/2181**], s/p POBA for ISR in 2/[**2185**].
End-stage renal disease s/p renal transplant in [**2180**]
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Gout
Diabetes-type II
HSV meningitis in [**2184**]
Cardiomyopathy-EF 35-40%
Spinal stenosis
Sciatica chronic back pain and left hip pain
s/p AV fistula for HD in the past
Tonsillectomy as a child
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. He is a semi-retired
yaught charter organizer. He lives in [**Location 2312**] with his wife.
[**Name (NI) **] is married with 4 children.
Family History:
Father died of MI in early 60s, brother died of MI age 53.
Mother with diabetes.
Physical Exam:
Weight is 198 pounds, blood pressure is 140/60,pulse is 70
GENERAL: Gait is stable.
HEENT: PERRLA, EOMI, oropharynx is clear
NECK: Supple, full range of motion
HEART: RRR, S1, S2, no gallop
CHEST: Clear to auscultation, no rales or wheezes
ABDOMEN: Soft and nontender, non-distended
EXTREMITIES: He does have a large ecchymosis, which is improving
by his report in the left hip. Extremities, mild peripheral
edema.No varicosities
Neuro: non-focal, alert and oriented x 3
Pertinent Results:
[**2186-5-16**] Cath: 1. Selective coronary angiography of this left
dominant system with known occluded right coronary artery
revealed three vessel disease. The LMCA had a 60% calcified
stenosis. The LAD had a total occlusion in the mid segment at
the previously placed stents (Taxus within a Cypher). There were
no collaterals supplying the LAD territory. The LCX had a 40%
stenosis at the proximal segment and the origin of the OM1 had a
70% stenosis. The OM@ had mild disease. The OM3 had a proximal
50% stenosis. The OM4 had a 70% stenosis at its origin, which
was focal in nature. The LPDA had mild disease. 2. Angiography
of the LIMA revealed a patent vessel. This was done in
anticipation of likely upcoming surgery. 3. Resting hemodynamics
demonstrated systolic arterial hypertension with central aortic
pressure of 163/78 mm Hg.
[**5-17**] CT: 1. No evidence of retroperitoneal bleed. 2. Stable
splenic and lung calcifications likely represent the sequela of
prior granulomatous disease. 3. Extensive atherosclerotic
calcifications are similar to [**2186-1-12**]. 4. Cholelithiasis without
evidence of cholecystitis.
[**5-17**] Carotid U/S: There is less than 40% stenosis within the
internal carotid arteries bilaterally.
[**2186-5-19**] Echo: 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. The interatrial septum is
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. 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 40
cm from the incisors. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results on Mr. [**Known lastname **] at 8AM. Post_Bypass: Normal RV systolic
function. Mild improved in the mid and apical anterior walls of
LV. LVEF 40% to 45% Intact thoracic aorta. Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **].
IABP is in place approx 4 cm below the left subclavian artery.
[**2186-5-21**] CXR: NG tube, ET tube, left chest tube, and mediastinal
drains have been removed. The Swan-Ganz catheter was replaced by
right internal jugular line with its tip being at the level of
mid SVC. There is no pneumothorax, pulmonary edema, or increased
pleural effusion. The left retrocardiac atelectasis is
unchanged.
[**2186-5-16**] 04:15PM BLOOD WBC-8.7 RBC-3.82* Hgb-10.4* Hct-32.9*
MCV-86 MCH-27.3 MCHC-31.7 RDW-17.2* Plt Ct-220
[**2186-5-23**] 05:40AM BLOOD WBC-10.3 RBC-2.82* Hgb-8.3* Hct-24.8*
MCV-88 MCH-29.6 MCHC-33.6 RDW-17.5* Plt Ct-161
[**2186-5-16**] 04:15PM BLOOD PT-20.9* PTT-27.6 INR(PT)-2.0*
[**2186-5-23**] 05:40AM BLOOD PT-14.7* INR(PT)-1.3*
[**2186-5-16**] 04:15PM BLOOD Glucose-131* UreaN-46* Creat-1.7* Na-138
K-4.3 Cl-104 HCO3-25 AnGap-13
[**2186-5-23**] 05:40AM BLOOD Glucose-65* UreaN-86* Creat-2.1* Na-136
K-4.1 Cl-104 HCO3-26 AnGap-10
[**2186-5-21**] 01:04AM BLOOD Calcium-8.4 Phos-5.2* Mg-2.6
[**2186-5-17**] 04:10AM BLOOD %HbA1c-6.3*
Brief Hospital Course:
As mentioned in the history of present illness, Mr. [**Known lastname **]
presented to [**Hospital1 **] with chest pain. He was ruled in for ST segment
myocardial infarction and was brought for a cardiac cath. Cath
revealed occluded LAD at previous stent placement along with 60%
left main disease. Balloon angioplasty was performed to LAD and
a Intra-aortic balloon pump was placed. Post-cath he was brought
to the ICU for further management. Hematocrit dropped after cath
and he received a blood transfusion along with CT to rule-out
retroperitoneal bleed (CT was negative). He remained stable in
the ICU while awaiting surgery and required other diagnostic
studies prior to bypass surgery. On [**5-19**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 5. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. On post-op day one the balloon pump was
removed and he was weaned from sedation, awoke neurologically
intact and extubated. On post-op day two he was transferred to
the telemetry for further care. Chest tubes and epicardial
pacing wires were removed per protocol. Physical therapy
followed patient during his post-op course and at time of
discharge felt he would require additional rehab due to weakness
and history of falls. On post-op day four he was discharged to
rehab with appropriate medications and follow-up appointments.
Medications on Admission:
ALENDRONATE 5 mg daily, ALLOPURINOL 100 mg daily, ATORVASTATIN
40 mg daily, CALCITRIOL 0.25 mcg daily, CARVEDILOL 3.125 mg
Tablet twice daily, ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit
Capsule monthly x 6, FENTANYL - 25 mcg/hour Patch 72 hr - apply
transdermally q72 hours, FUROSEMIDE 40 mg Tablet - 1 Tablet(s)
by mouth qd and takes [**12-16**] at hs prn, GLIPIZIDE 2.5 mg Tablet
Extended Rel 24 hr (2) - 1 Tab(s) by mouth twice a day [**First Name8 (NamePattern2) **]
[**Last Name (un) **], LISINOPRIL 5 mg daily, OXYCODONE - 5 mg Tablet - take
[**12-16**] Tablet(s) by mouth three times
a day as needed for pain (28 day supply), PREDNISONE 5 mg daily,
QUININE SULFATE - 324 mg nightly as needed for as needed for
cramps, TACROLIMUS[PROGRAF] 0.5 mg twice a day per transplant
clinic, TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM] - 80-400 mg 3
times per week per transplant clinic,
WARFARIN 1 mg - 4 Tablet(s) by mouth Daily as directed by
coumadin clinic, ASPIRIN 81 mg daily, COLACE 100mg Capsule daily
as needed, ISULIN REGULAR HUMAN[HUMULIN R] inject subcutaneously
per sliding scale as needed, OMEPRAZOLE MAGNESIUM 20 mg twice a
day
Plavix - last dose:600mg [**2186-5-16**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
[**12-16**] tablet (20mg) qPM.
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
Resume Coumadin per pre-op dose (4mg qd) and adjust for goal INR
around 2. Please check INR routinely.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
Myocardial infarction
Diabetes mellitus
Hypertension
Hyperlipidemia
Atrial fibrillation
Chronic renal insufficiency s/p renal transplant
Gastroesophageal reflux disease
Spinal stenosis and Sciatica - chronic back pain
HSV meningitis in [**2184**]
Gout
s/p left AV fistula
s/p Tonisllectomy
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**12-16**] weeks
Dr. [**First Name (STitle) 437**] in [**1-17**] weeks
Completed by:[**2186-5-23**] Name: [**Known lastname **],[**Known firstname **] W Unit No: [**Numeric Identifier 5004**]
Admission Date: [**2186-5-16**] Discharge Date: [**2186-5-23**]
Date of Birth: [**2118-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 1543**]
Addendum:
It should be noted that in addition to the medications stated in
the dischrge summary Mr [**Known lastname **] was also discharged on Bactrim
80/400, one tab 3x/week. This is his preoperative schedule per
the renal transplant service.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2186-5-23**]
|
[
"427.31",
"414.01",
"428.22",
"585.9",
"414.2",
"274.9",
"410.11",
"272.4",
"428.0",
"530.81",
"996.72",
"250.00",
"412",
"V42.0",
"724.00",
"414.8",
"724.3",
"403.90",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"00.66",
"99.20",
"88.55",
"36.14",
"88.52",
"39.61",
"37.36",
"00.40",
"36.15",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
11646, 11871
|
5799, 7274
|
298, 612
|
10302, 10308
|
2425, 5776
|
10851, 11623
|
1829, 1911
|
8499, 9819
|
9929, 10281
|
7300, 8476
|
10332, 10828
|
1926, 2406
|
248, 260
|
640, 963
|
985, 1548
|
1564, 1813
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,139
| 142,512
|
10415
|
Discharge summary
|
report
|
Admission Date: [**2132-6-5**] Discharge Date: [**2132-7-11**]
Date of Birth: [**2061-9-24**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Oxacillin / Heparin Agents
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
.
History of Present Illness:
70 yo M with history of ESRD on HD, multiple MRSA line
infections, atrial fibrillation, and CAD who is admitted to the
MICU for respiratory distress.
.
The patient was noted at dialysis on the day prior to admission
to have a fever to 102 with altered mental status and was sent
to the [**Hospital1 18**] ED. He was admitted to the general medicine service
on [**2132-6-5**] with fever and lethargy. On the floor, the patient
was continued on Vancomycin for likely HD line infection. An LP
was not performed given that the pt's lethargy had improved and
he was thought to be at his baseline mental status. He was
started on Levofloxacin this morning for GNR in his blood.
.
The patient had been doing well until today. 35 minutes after
initiating dialysis (with 500cc fluid removal), the pt began
having rigors with shortness of breath. His temperature
increased to 101.7, BP was 203/126 with HR 122. His oxygen
saturation decreased to 88% RA. He was given a nebulizer with
slight improvement in his subjective complaints of dyspnea. He
was initially placed on 5L NC which was titrated up to 15L NRB
mask. The MICU was called for evaluation.
Past Medical History:
1. ESRD (unclear etiology) on HD M/W/F s/p R cadaveric tx '[**19**] at
[**Hospital1 2177**], failed '[**29**], removed [**6-26**]
2. Staph aureus (sensitive to Ox, resistant to PCN) sepsis,
recent line infections; [**2131-5-24**] micro data
3. HTN
4. AFib
5. DDD PCM
6. CAD - mild 40% prox LAD on cath '[**27**]
7. LUE DVT
8. L TKR '[**23**]
9. Hypothyroidism
10. Hx of TB as child, PPD neg
Social History:
Retired dentist living in [**Location (un) **] with wife, kids, and
[**Name2 (NI) 7337**], denies etoh/tob.
Family History:
Both parents died in 90's, healthy.
Physical Exam:
Vitals: T 102.7 BP 108/40 HR 90 RR 26 99% on 100% NRB
Gen: ill-appearing man in respiratory distress, answers
questions yes and no, diaphoretic
HEENT: dry mucous membranes, PERRL, EOMI
Neck: supple, JVP ~[**8-2**]
Lungs: diffuse crackles with decreased breath sounds and
dullness to percussion in bilateral lower lobes
Cor: RRR, nml S1S2
Abd: NABS, soft NTND
Ext: warm, no edema, previous fistula RUE
Brief Hospital Course:
1. Hypoxic respiratory failure: Etiology of respiratory
distress/failure not entirely clear. CXR reveals slightly
increased vascular markings and new cuffing, concerning for
possible volume overload though compared to last several months
the CXR is not that different. This CXR was after the patient
was acutely hypertensive to 203/126 with HR 122, which could
point to possible flash pulmonary edema. Given hx of DVT, can
also consider PE, especially with large A-a gradient. Pt also
has element of hypoventilation with poor oxygenation by ABG.
gave pt trial of BiPAP to see if pt appeared more comfortable,
pt's respiratory status did not improve and pt appeared
uncomfortable. Pt intubated, received CTA to r/o PE. Pt
tolerated intubation but attempts to wean from ventilator
unsuccessful. Pt developed opacity on CXR suggestive of pna and
abx treatment initiated once MRSA pneumonia identified; however,
pt's respiratory distress did not resolve c vancomycin x 19
days. Trach placed and pt weaned on ventilator. Pulmonary edema
noted on CXR and pt diuresed gently because prone to hypotension
particularly c hemodialysis. Required assist control but
eventually weaned to pressure support. Currently, limiting
factor largely pt's respiratory muscle weakness 2/2 prolonged
hospitalization. Pt has tolerated PS x 7 days and nights.
Yesterday also tolerated trial sprint of [**3-27**] although became
tachypneic. Partly [**12-26**] anxiety--> will try ativan during
sprints.
-In effort to improve resp muscle weakness continue sprints of
lower pressure for 45 mins until pt SOB/tachpneic c return to
higher pressure afterwards to allow pt to rest
-Placed passe valve
.
2. Sepsis: Pt with elevated lactate, fevers and hypotension
(after intubation) pointing to sepsis. Likely line infection
from femoral dialysis catheter. Blood cultures growing GNR and
GPC. Will discontinue dialysis line. Continue Levofloxacin for
GNR (which are sensitive) and Vanco given hx of staph aureus
line infections. After abx course pt continued to have
intermitent feverss and multiple episodes fo MAP dropping into
30-40s. Initially treated c multiple IVF boluses. However, pt
eventually required levophed to maintain MAP>60. Etiology of
hypoT likely sepsis and hypovolemia as pt had CVPs<10 and
hypotension worse after hemodialysis. Pt eventually grew
Serratia out of his blood cultures and was treated c a 21 day
course of ceftaz. In addition, his dialysis cath was pulled and
a new one placed. Afterwards, he continued to have low grade
fevers and developed the aforementioned LLL pna. Also, his R
femoral line was pulled and grew Coag- staph. Therefore he was
started on a 7 day course of meropenem and vancomycin. On this
regimen his LLL opacity has resolved and his fever curve has
turned downward. He has since had no positive blood cultures. Pt
currently no WBC, no tachyc and today hypertensive c MAPs>75.
Bld cx NGTD. Stool neg for C diff. TTE no signs of IE.
3. ESRD: Received hemodialysis initially and then was
transitioned to CVVH. Once his BP tolerated he was transitioned
back to HD. Followed by Renal Service throughout. The pt did not
make any urine throughout his stay. With HD his BP initially
dropped. Therefore, his HD was spaced out and less fluid was
withdrawn during each session. Attempts were made to keep the pt
net fluid negative during the week. Pt c temporary dialysis cath
in place and will require more permanent line eventually. Pt
required supplementation of his phosphate c neutraphos regularly
and briefly reqrd recalcitrol. Pt currently tolerating removal
of 2kg of fluid via HD three times a week. Holding beta blocker
on dialysis days to prevent instigation of hypotension. -Per
Renal pt will eventually require more permanent access.
4. [**Name (NI) 3674**] Pt's Hct repeatedly dropped over last three weeks
requiring multiple transfusions. Etiology unknown. Possibly [**12-26**]
GI bleed as pt c h/o melanic stools, Guiac positive regularly,
and on significant anticoagulation c argatroban/coumadin. RBC
scan negative for GI bleed. Alternatively, maybe [**12-26**] ESRD. Pt
given epo [**Hospital1 **]. Also, maybe [**12-26**] Fe deficiency and so pt given
iron supplements. Currently Hct stable x 5ds off
anticoagulation. Following Hcts [**Hospital1 **] and remained in low 30s.
Will restart anticoagulation. Transfuse for Hct<25. Pt will
require colonoscopy/EGD as outpt to further eval guiac positive
stools.
.
.
5. Atrial fibrillation: Intermittently V-paced. Pt c one episode
of tachycardia c rate controlled c diltiazem. Otherwise no
incidents. Pt's anti-coagulation held for one week while Hct
unstable. Currently Hct stable and restarted coumadin. Goal INR
2-
6. [**Name (NI) 34483**] Pt c h/o HIT and also upper extremity clots so not
started on heparin. Anti-coagulated in hospital c argatroban and
then transitioned to coumadin. Anticoagulation held while pt's
Hct unstable.
.
7. FEN: Pt tolerating tube feeds via PEG tube. Requires
intermitent supplementation of phosphate c neutraphos based on
low serum phosphate.
.
8. Access: Right IJ in place c 3 ports, 2 of which are dedicated
for use only c CVVH. R femoral removed and grew coag negative
staph. IR reluctant to place on R as stent from IJ to SVC. On
left pt has braciocephalic clot preventing PIC placement. Pt now
c 1 peripheral IVs.
9. PPX: Pneumoboots. PPI, Coumadin
.
10. Full Code
.
10. Communication: Wife and daughter
Medications on Admission:
[**Name (NI) **] 325 qd
Folate
Vitamin B12
Ranitidine
Amiodarone 200 qd
Timolol 1 gtt
Lopressors 25mg tid
Coumadin 2g qd
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily). Tablet(s)
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Albuterol Sulfate 0.083 % Solution Sig: [**11-25**] Inhalation Q4H
(every 4 hours) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Hold if SBP<120.
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): Continue until no longer see thrush in mouth.
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: For anxiety when pt's resp rate increases
significantly.
15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
16. Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily): Check INR daily for goal INR of [**12-28**].
17. Outpatient Lab Work
Please check INR daily while pt on coumadin. Goal INR of [**12-28**].
Adjust dose accordingly.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
End Stage Renal Disease, Sepsis, Pneumonia, Line Infection,
Anemia, Gastrointestinal Bleed
Discharge Condition:
stable
Discharge Instructions:
Please return to the ED or call your doctor if you have
shortness of breath, chest pain or any concerns at all.
Followup Instructions:
Follow-up with your Primary Care doctor this week.
|
[
"518.81",
"038.44",
"996.62",
"482.41",
"995.92",
"V09.0",
"578.1",
"785.52",
"038.11",
"427.31",
"403.91",
"V43.65",
"428.0",
"V58.61",
"244.9",
"280.0",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.72",
"88.67",
"43.11",
"96.04",
"96.6",
"88.72",
"00.17",
"38.95",
"39.95",
"93.90",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9793, 9898
|
2531, 7952
|
320, 323
|
10033, 10042
|
10202, 10256
|
2053, 2090
|
8123, 9770
|
9919, 10012
|
7978, 8100
|
10066, 10179
|
2105, 2508
|
269, 282
|
351, 1496
|
1518, 1911
|
1927, 2037
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,565
| 147,907
|
5149
|
Discharge summary
|
report
|
Admission Date: [**2142-5-6**] Discharge Date: [**2142-6-4**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
nausea, abdominal pain, and bilious emesis consistent with small
bowel obstruction
Major Surgical or Invasive Procedure:
4/16 L inguinal hernia repair
[**5-17**] thoracentesis
[**5-23**] tracheostomy/PEG placement
History of Present Illness:
The patient is an 85 y/o F with abdominal pain X3 days with
nausea
and vomiting nonbloody bilious emesis. She has not had a BM
X5 days and reports feeling quite distended. She is
passing only minimal if any flatus. Her pain is global and
crampy in nature. It does not radiate. This has never happened
to her before. She is not tolerating po's. The patient denies
any fevers, chills, rhinorrhea, cough, sore throat, chest pain,
shortness of breath, dysuria, hematuria, BRBPR, travel, sick
contacts, strange foods. She reports that she has been
urinating
a normal amount but that it is a little dark. She has not been
taking her lasix. NGT was placed by ER which immediately put
out
2200 cc bilious material. She reports feeling significantly
better since decompression. Virtual colonoscopy in [**Month (only) 958**]
revealed 3.2 x 2.4 cm polypoidal villous-type adenoma in the
right colon. EGD essentially negative at that time.
Past Medical History:
Pancreatic cyst, Mitral valve disease, Severe tricuspid
regurgitation, Aortic regurgitation, History of rheumatic fever,
MVR, Chronic atrial fibrillation, Congestive heart failure, Iron
deficiency anemia, Hypertension, Seizure disorder, CCY, Left
inguinal hernia, Cerebellar infarcts
Social History:
No alcohol. No cigarette smoking. She is accompanied by
her son at the time of presentation
Family History:
non contributory
Physical Exam:
At the time of discharge:
- Vitals stable (afebrile, HR in 70s, SBP ~120), maintaining
adequate oxygenization on trach collar during the day, CPAP
overnight
- sleepy but arousable, alert, and conversant
- lungs with crackles and diminished breath sounds bilaterally
- heart irregular
- abdomen soft but distended, G-tube in place without erythema
or drainage; midline incision clean, dry, and intact with
steri-strips intact; no significant tenderness to palpation
- 1+ peripheral edema
Pertinent Results:
At the time of discharge:
- her INR was therapeutic on oral coumadin with a level of 3.6
on [**6-4**]
- her WBC was normal, and was 6.8 on [**6-4**]
- her hematocrit was stable and 27.8 without evidence of
bleeding
- of note, her serum bicarbonate had increased slowly to a level
of 45 on [**6-4**], with current plan to begin acetazolamide to
normalize her labs
Brief Hospital Course:
The patient presented to the [**Hospital1 18**] ED, and underwent a KUB which
demonstrated multiple dilated loops of small bowel consistent
with a small bowel obstruction. She was admitted, resuscitated
with IVF, and underwent serial examinations.
The cardiology service was consulted for assistance with
management. She was loaded with digoxin, given vitamin K to
reverse her coumadin, and started on a heparin drip for
anticoagulation.
Her bowel obstruction did not clinically improve, and she was
therefore taken to the operating room on [**2142-5-10**] for lysis of
adhesions and L inguinal hernia repair. There was no evidence
of intestinal ischemia at that time, and no bowel was resected.
She tolerated the procedure somewhat well, although she did
require vasopressors during the case.
She ultimately had difficulty weaning from ventilatory support,
and she was extubated [**5-15**] and subsequently re-intubated. She
was found to have pleural effusions, and given the tenuousness
of her respiratory status, she underwent thoracentesis on [**5-17**]
where 700 cc of fluid was removed.
Despite this, she continued to require ventilatory support and
discussions were undertaken regarding the utility of
tracheostomy and PEG placement. The family agreed to this, and
on [**5-23**] she underwent bedside percutaneous tracheostomy and PEG
placement in the SICU, which she tolerated well.
She was thereafter transitioned back onto enteral coumadin once
she was tolerating tube feeds via her G-tube. Her current
clinical situation and plan, by system, will be described below.
Neuro: the patient's mental status at the time of discharge was
good - she is awake, alert, and responding appropriately to
commands (speaking with use of a PMV). Her pain was well
controlled peri-operatively, and she is experiencing no pain at
the time of discharge, requiring only occasional tylenol for
relief.
CV: She remained in atrial fibrillation throughout her hospital
course, and was appropriately rate-controlled with digoxin. She
had no significant hemodynamic events during her ICU stay. She
remained anti-coagulated and was on coumadin at the time of
discharge for her mechanical valve. Her home lopressor and
lisinopril doses had not been resumed, although should she
develop hypertension this can be re-started at rehab.
Pulm: as described above, she had significant difficulty weaning
ventilatory support throughout her hospital stay, and eventually
underwent tracheostomy. She was treated for pneumonia
transiently with vancomycin/zosyn but was off all antibiotics at
the time of discharge. Her ventilatory support was weaned
slowly, and at the time of discharge she was tolerating trach
collar during the day and was being rested overnight on CPAP
[**10-29**] for mild tachypnea. Her tracheostomy site was clean, dry,
and intact without bleeding.
GI: following her exploratory laparotomy and hernia repair, the
patient slowly regained bowel function. She began to pass
flatus and have BMs, and continued to do this at the time of
discharge. Of note, the patient failed speech and swallow on
[**2142-5-31**] largely because of her respiratory status at the time.
At the time of discharge, the patient was tolerating her tube
feeds at goal (nutren pulmonary at 35cc/hr), and although she
had mild abdominal distention she had no nausea or vomiting.
Her abdominal incision was clean, dry, and intact without
breakdown, erythema, or discharge.
GU: she has a foley catheter and has continued to make adequate
urine output throughout the duration of her hospital stay
(>25cc/hr). At the time of discharge, she had developed a
metabolic alkalosis and was receiving acetazolamide and holding
her home dose of lasix, although this can be re-started at rehab
if her bicarbonate normalizes.
Heme: As mentioned above, she was transitioned to a heparin drip
throughout her hospital stay (which was titrated), and following
PEG placement was transitioned back to enteral coumadin. She
had received doses of 10 mg, 7.5 mg, and 5mg, and at the time of
discharge her INR was 3.6 and she was receiving 5 mg daily.
This will need to be titrated at rehab for goal INR 2.5 - 3.5.
ID: The patient was empirically treated for pneumonia during her
hospital stay but by the time of discharge was afebrile, off all
antibiotics, and with a normal WBC count. She had no evidence
of any infectious process at the time of discharge.
She was being screened for ventilatory rehab because of her
tracheostomy and requirement for the ventilator.
Medications on Admission:
DIGOXIN 125'
Lasix 80'
Lisinopril 10'
Toprol 100'
Coumadin 5'
Ca
Vit D
Iron 325'
Discharge Medications:
Acetazolamide 250 mg IV Q12hrs (no lasix at this time)
Digoxin 0.125 mg daily
Colace, Senna
MVI
Insulin SS
Coumadin 5 mg daily (to be titrated)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p small bowel obstruction secondary to hernia
respiratory failure s/p tracheostomy
Pancreatic cyst
Mitral valve disease
Severe tricuspid regurgitation
Aortic regurgitation
history of rheumatic fever
MVR
Chronic atrial fibrillation
Congestive heart failure
Iron deficiency anemia
Hypertension
Seizure disorder
s/p CCY
Cerebellar infarct
Discharge Condition:
stable
Discharge Instructions:
Please continue tracheostomy care and routine g-tube care.
Please leave steri-strips on abdominal incision and allow them
to fall off over time.
Please call your doctor or return to the Emergency Department
for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
please call Dr.[**Name (NI) 2829**] office ([**Telephone/Fax (1) 1231**]) to schedule a
follow-up appointment in 2 weeks.
Completed by:[**2142-6-4**]
|
[
"560.81",
"345.90",
"518.81",
"V43.3",
"E934.2",
"285.21",
"486",
"584.9",
"396.2",
"397.0",
"790.92",
"398.91",
"511.9",
"276.3",
"550.11",
"V58.61",
"585.9",
"427.31",
"V12.54",
"276.0",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.6",
"33.21",
"43.11",
"99.15",
"33.24",
"96.04",
"31.1",
"96.72",
"54.59",
"53.00"
] |
icd9pcs
|
[
[
[]
]
] |
7613, 7692
|
2770, 7312
|
341, 436
|
8075, 8083
|
2382, 2747
|
9275, 9427
|
1841, 1859
|
7444, 7590
|
7713, 8054
|
7338, 7421
|
8107, 9252
|
1874, 2363
|
219, 303
|
464, 1406
|
1428, 1713
|
1729, 1825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,820
| 167,977
|
22503
|
Discharge summary
|
report
|
Admission Date: [**2124-2-8**] Discharge Date: [**2124-2-12**]
Date of Birth: [**2047-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, fatigue
Major Surgical or Invasive Procedure:
CABG x3(Lima->LAD, SVG->Ramus/OM)-[**2-7**]
History of Present Illness:
76 year old Spanish speaking male complaining of exertional
chest pain and fatigue. Abnormal stress test referred for
cardiac catheterization which revealed 3 vessel disease.
Dr.[**Last Name (STitle) **] consulted for coronary revascularization.
Past Medical History:
HTN
hyperlipidemia
DMII
Nephrolithiasis, s/p surgery for renal calculi
Hypothyroidism
Cataracts
GERD
s/p MI
Social History:
Spanish speaking, from [**Last Name (STitle) 7196**]
Unemployed
His wife lives in [**Name (NI) 7196**]
Son and daughter live in [**Name (NI) **]
quit tobacco 20 years ago
denies ETOH
Family History:
noncontributory/denies
Physical Exam:
Discharge
VS: 98.8 128/56 72 18 95% RA 77.3KG
General: Pleasant, speaks through spanish interpreter
CVS: regular rate, no murmurs, rubs, gallops appreciated
Lungs: clear to auscultation bilaterally
ABD: flat and nontender with normoactive bowel sounds
EXTR:warm with trace edema
Wound/incision:clean and dry, sternum stable
Pertinent Results:
[**2124-2-8**] 01:52PM BLOOD WBC-7.1 RBC-3.46* Hgb-10.6* Hct-29.9*
MCV-87 MCH-30.8 MCHC-35.6* RDW-13.5 Plt Ct-148*
[**2124-2-11**] 06:48AM BLOOD WBC-7.8 RBC-2.94* Hgb-8.9* Hct-25.7*
MCV-87 MCH-30.3 MCHC-34.7 RDW-14.0 Plt Ct-133*
[**2124-2-8**] 01:52PM BLOOD PT-14.5* PTT-36.8* INR(PT)-1.3*
[**2124-2-9**] 02:05AM BLOOD Glucose-78 UreaN-18 Creat-0.8 Na-137
K-4.2 Cl-109* HCO3-23 AnGap-9
[**2124-2-11**] 06:48AM BLOOD Glucose-51* UreaN-26* Creat-1.0 Na-137
K-4.4 Cl-106 HCO3-23 AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 58427**] [**Hospital1 18**] [**Numeric Identifier 58428**] (Complete)
Done [**2124-2-8**] at 11:39:06 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
[**Last Name (LF) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2047-9-21**]
Age (years): 76 M Hgt (in): 72
BP (mm Hg): 108/57 Wgt (lb): 178
HR (bpm): 58 BSA (m2): 2.03 m2
Indication: coronary artery disease, intraop management for CABG
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2124-2-8**] at 11:39 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW2-: Machine: 1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.8 cm
Left Ventricle - Fractional Shortening: *0.21 >= 0.29
Left Ventricle - Ejection Fraction: 40% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.3 cm <= 3.0 cm
Aorta - Ascending: 2.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *1.4 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. 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. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Moderately
dilated LV cavity. Inferobasal LV aneurysm. Mild-moderate
regional LV systolic dysfunction.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Complex (>4mm) atheroma in
the aortic arch. Normal descending aorta diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). No AR.
MITRAL VALVE: Moderate mitral annular calcification. Mild (1+)
MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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. Suboptimal image
quality - poor echo windows. Results were personally reviewed
with the MD caring for the patient.
Conclusions
PRE BYPASS - poor echo images
1. No spontaneous echo contrast or thrombus is seen in the body
of the left atrium or left atrial appendage. No atrial septal
defect or PFO is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal and cavity is
moderately dilated. There is an inferobasal left ventricular
aneurysm with aneurysm wall dyskinesis. There is mild to
moderate regional left ventricular systolic dysfunction with
mild hypokinesis of the septum and inferior septum with severe
hypokinesis of the inferior and inferolateral walls.
3. There are simple atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
4. The number of aortic valve leaflets cannot be determined -
likely three. The aortic valve leaflets are moderately
thickened. The right coronary cusp is immobilized. There is mild
aortic valve stenosis (area 1.4 cm2). No aortic regurgitation is
seen.
5. At least mild (1+) mitral regurgitation is seen but poor
image quality prevents full assessment.
6. There is no pericardial effusion.
7. Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POSTBYPASS - echo images have improved greatly
1. Patient is on phenylephrine
2. Left ventricle function has improved, EF now 50%. The
aneurysm of the inferiobasal wall is better visualized, with
continued dyskinesis of the involved wall. The inferior wall
distal to the aneurysm appears to have good function.
Inferoseptal hypokinesis has resolved.
3. Mitral regurgitation is better visualized and is graded mild.
4. Aortic contour is smooth after decannulation. .
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2124-2-8**] 14:46
[**Known lastname **],[**Known firstname 58427**] [**Medical Record Number 58429**] M 76 [**2047-9-21**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2124-2-10**]
11:12 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA5 [**2124-2-10**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 58430**]
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval for pneumothorax s/p chest tube removal
Final Report
CLINICAL HISTORY: Status post CABG, chest tube removed. Evaluate
for
pneumothorax.
CHEST:
Since the prior chest x-ray, all the tubes and lines have been
removed. Some
atelectasis at the left base is present. There is a small apical
pneumothorax
present on the left. Atelectasis in the right base is seen. No
failure is
present.
IMPRESSION: Small apical left pneumothorax.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: [**First Name8 (NamePattern2) **] [**2124-2-10**] 12:31 PM
Imaging Lab
Brief Hospital Course:
[**2-7**] Mr.[**Known lastname **] was taken to the operating room and underwent
cornary artery bypass grafting x 3 (left internal mammery artery
grafted to the left anterior descending artery/ saphenous vein
grafted to the ramus and saphenous vein grafted to the obtuse
marginal. Please refer to Dr[**Last Name (STitle) **] operative report for
further details. He was transferred to the CVICU intubated,
sedated requiring external pacing for bradycardia in the 40s
post pump. Sedation was weaned, he awoke neurologically intact
and he was extubated without difficulty. Neosynephrine was
weaned to off and all lines were discontinued in a timely
fashion. POD#1 he was transferred to the step down unit for
further monitoring. Beta-blocker, statin, ACE-I and aspirin were
initiated. Chest tubes were dc'd when drainage criteria was met
on POD#2. He continued to progress and it was felt he was ready
for discharge on POD#4. Social work was consulted to assist with
appropriate after care, based on limited family support and
Mr.[**Known lastname 58431**] lack of need for a rehab. All follow up
appointments were advised.
Medications on Admission:
Glyburide 5mg in AM/ 2.5mg PM
Metformin 500(2)
Levothyroxine 50mcg(1)
Atenolol 25(1)
Lisinopril 10(1)
ASA 325(1)
Simvastatin 40(1)
Discharge Medications:
1. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Metformin 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
s/p CABG x3(Lima->LAD, SVG->Ramus/OM)-[**2-7**]
HTN
DMII
hypothyroidism
Nephrolithiasis, s/p surgery for renal calculi
Cataracts
GERD
MI 10yo
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) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) **] in 1 week please call for appointment
Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] B. in [**3-14**] weeks ([**Telephone/Fax (1) 17826**])
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2124-2-12**]
|
[
"401.9",
"250.00",
"366.8",
"413.9",
"244.9",
"412",
"530.81",
"V13.01",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10878, 10897
|
8594, 9718
|
340, 386
|
11083, 11090
|
1397, 7839
|
11602, 12018
|
1008, 1032
|
9899, 10855
|
7879, 7904
|
10918, 11062
|
9744, 9876
|
11114, 11579
|
1047, 1378
|
281, 302
|
7936, 8571
|
414, 661
|
683, 792
|
808, 992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,051
| 141,857
|
38754
|
Discharge summary
|
report
|
Admission Date: [**2105-5-22**] Discharge Date: [**2105-6-3**]
Date of Birth: [**2031-10-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Neomycin Sulfate / Neomycin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
Intubation [**5-22**]
Esophagoduodenoscopy
Colonoscopy
History of Present Illness:
Ms. [**Known lastname 77625**] is a 73yo F with h/o CRI presenting with narrow
complex tachycardia and anemia. Has not seen a doctor in 30
years and according to patient and family have been worried
about weight loss and laxative abuse at home. Has been using mag
citrate excessively at home. Came into PCP today because
daughter was concerned that patient was feeling so weak at home.
Also, after discussion with her friend she was complaining of
increased diarrhea at home.
At PCP's office EKG was HR in 180s so transferred here.
In the ED, initial vs were: T 98.9 HR170 BP115/78 RR20 O2Sat100.
Looked like SVT on EKG in ED and broke off and on in ED on tele.
After she broke is in sinus without ST changes. CXR normal. 2
PIVs. Mentating appropriately the whole time. Trop slightly
elevated in setting of CRI. Also, got 1L NS, 40PO KCL, 40 IV
KCL, 2gm calcium gluconate, and 2 gms mag sulfate. Consented for
2 units pRBCs. HR now slower on 10 IV dilt and 30 po dilt. Never
got adenosine. Currently controlled in 90s. Guaiac negative but
no stool in vault in ED. No abdominal tenderness. Prior to
transfer vitals were: HR:86 T:97.6 BP:101/56 O2Sat:97%RA.
On the floor, her initial VS were: T: 97.1, HR: 98, BP: 107/67,
RR: 18, 100% on RA. She had no complaints except feeling more
fatigued recently. She had some bursts of SVT into the 160s but
would come down to NSR without intervention. One unit of pRBCs
was hung upon arrival to the ICU. She also received 1gm calcium
chloride upon arrival.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies cough, shortness
of breath, or wheezing. Denies chest pain, chest pressure,
palpitations. Denies nausea, vomiting, diarrhea, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies melena, BRBPR, hematemesis.
Past Medical History:
CRI
Alcoholic Cirrhosis last drink in [**2065**]. Last INR 1.2 in [**2104**].
Albumin and transaminases normal at that time.
Retinal Vein Occlusion
Ocular hypertension
Glaucoma
PSHx:
Cataract extraction
Social History:
Lives alone. Daughter recently passed away from drugs/etoh. Has
six children and is one of 16 herself.
- Tobacco: Former. Quit in [**2070**].
- Alcohol: History of alcoholism and hospitalized at the [**Hospital1 86076**] in the [**2065**]. Sober since then.
- Illicits: None
Family History:
Mom died of unknown cancer. Daughter died of drugs and alcohol.
Physical Exam:
Vitals: T: 97.1 BP:100/52 P:78 sinus with PACs R:18 18 O2: 100%
2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, crackles at bilateral
bases
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley. Guaic positive brown stool with normal rectal tone
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2105-5-22**] 01:23PM WBC-10.1 RBC-3.04* Hgb-5.0* Hct-19.8* MCV-65*
Plt Ct-583*
[**2105-5-22**] 01:23PM Neuts-75.9* Lymphs-19.8 Monos-3.6 Eos-0.4
Baso-0.3
[**2105-5-22**] 01:23PM PT-15.2* PTT-29.0 INR(PT)-1.3*
[**2105-5-22**] 01:23PM Fibrino-666*
[**2105-5-22**] 01:23PM Glucose-117 UreaN-22 Creat-1.7 Na-141 K-2.9
Cl-96 HCO3-27
[**2105-5-22**] 01:23PM ALT-8 AST-21 CK(CPK)-276* AlkPhos-100
TotBili-0.3
[**2105-5-22**] 01:23PM cTropnT-0.05*
[**2105-5-22**] 01:23PM Albumin-3.1* Calcium-5.2* Phos-3.3 Mg-1.1*
Iron-11*
[**2105-5-22**] 01:23PM calTIBC-319 Hapto-619* Ferritn-18 TRF-245
[**2105-5-22**] 01:23PM TSH-2.6
[**2105-5-22**] 01:23PM PTH-510*
[**2105-5-22**] 01:25PM Glucose-119* Lactate-3.3* Na-143 K-2.5*
[**2105-5-22**] 01:25PM Hgb-5.7* calcHCT-17
[**2105-5-22**] 07:01PM freeCa-0.84*
OTHER PERTINENT LABS:
[**2105-5-23**] 03:28AM Ret Man-2.1*
[**2105-5-23**] 07:51PM proBNP-[**Numeric Identifier **]*
[**2105-5-22**] 01:23PM ALT-8 AST-21 CK(CPK)-276* AlkPhos-100
TotBili-0.3
[**2105-5-26**] 04:43AM VitB12-692 Folate-4.9
[**2105-5-26**] 04:43AM Calcium-8.0* Phos-3.3 Mg-1.8 Cholest-117
[**2105-5-26**] 04:43AM Triglyc-99 HDL-36 CHOL/HD-3.3 LDLcalc-61
[**2105-5-23**] 05:52AM TSH-3.9
[**2105-5-22**] 09:04PM VITAMIN D [**2-16**] DIHYDROXY 22
CE TREND:
[**2105-5-22**] 09:04PM CK(CPK)-193
[**2105-5-23**] 03:28AM CK(CPK)-184
[**2105-5-23**] 07:51PM CK(CPK)-185
[**2105-5-24**] 02:45AM CK(CPK)-178
[**2105-5-22**] 01:23PM cTropnT-0.05*
[**2105-5-22**] 09:04PM CK-MB-2 cTropnT-0.04*
[**2105-5-23**] 03:28AM CK-MB-3 cTropnT-0.12*
[**2105-5-23**] 07:51PM CK-MB-9 cTropnT-0.19*
[**2105-5-24**] 02:45AM CK-MB-9 cTropnT-0.13*
URINE:
[**2105-5-22**] 11:09PM Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2105-5-22**] 11:09PM Blood-SM Nitrite-NEG Protein-30 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2105-5-22**] 11:09PM RBC-9* WBC-290* Bacteri-NONE Yeast-NONE Epi-7
[**2105-5-22**] 11:07PM Hours-RANDOM Creat-69 Na-43 K-29
[**2105-5-22**] 11:07PM Osmolal-314
[**2105-5-22**] 11:07PM U-PEP-NEGATIVE F
[**2105-6-2**] 04:19AM Hours-RANDOM Calcium-19.0
MICROBIOLOGY:
[**5-22**] UCx: BETA STREPTOCOCCUS GROUP B. >100,000 ORGANISMS/ML
[**5-24**] and [**5-27**] UCx: NEGATIVE
[**5-23**] and [**5-24**] SputumCx: Yeast ~1000 colonies, rare
[**5-26**] RPR: non-reactive
[**5-27**] BCx: NEGATIVE
[**5-30**] Hpylori Ab: POSITIVE
STUDIES:
[**5-22**] EKG:
Long R-P interval supraventricular tachycardia. Non-specific
ST-T wave
changes.
[**5-22**] CXR:
Left lower lung linear atelectasis versus scarring. Otherwise
unremarkable.
[**5-23**] ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 30 %) with anterior, septal and apical
akinesis. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**5-27**] CXR:
In comparison with the prior studies, there is continued
enlargement
of the cardiac silhouette with pulmonary edema. Some mild
atelectatic changes are seen at the bases. However, no evidence
of acute focal pneumonia.
[**5-27**] CT head:
1. No acute intracranial abnormality; specifically, there is no
evidence of hemorrhage or edema.
2. Clear included paranasal sinuses, middle ear cavities and
mastoid air
cells.
3. Well-defined lesion in the right frontovertex scalp soft
tissues; this
should be correlated directly with physical examination.
[**5-29**] EGD:
- Erythema and congestion in the gastroesophageal junction
compatible with esophagitis
- Mild erythema, mild atrophy in the stomach body compatible
with gastritis (biopsy)
- Small hiatal hernia
- Mild congestion and erythema in the antrum compatible with
gastritis (biopsy)
- Ulcer in the incisura (endoclip)
- The antrum was deformed, suggesting previous PUD. The tissue
around pyloric channel was edematous
- Granularity, erythema and congestion in the duodenal bulb and
first part of the duodenum compatible with duodenitis (biopsy)
- The duodenal bulb was deformed, suggesting previous PUD.
- Otherwise normal EGD to third part of the duodenum
Recommendations:
- follow-up biopsy results
- Pt needs repeat EGD to have biopsy from the ulcer to r/o
gastric CA while she is more stable.
- Pls check H. Pylori Ab
[**5-29**] Gastrointestinal mucosal biopsies, three:
A. Stomach, body:
1. Fundic mucosa with chronic inactive gastritis.
2. No intestinal metaplasia seen.
3. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6311**] stain is negative (satisfactory control).
B. Stomach, antrum:
1. Antral mucosa with chronic focally active gastritis.
2. No intestinal metaplasia seen.
3. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6311**] stain is negative (satisfactory control).
C. Duodenum:
Duodenal mucosa, no diagnostic abnormalities recognized.
[**6-1**] Colonoscopy:
4 polyps seen and removed for biopsy
diverticula noted
[**6-1**] Colon polyp biopsies: pending
[**6-1**] ECHO:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is mild (non-obstructive) focal hypertrophy
of the basal septum. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. An eccentric, posteriorly directed jet of moderate
(2+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2105-5-23**],
left ventricular systolic function is improved and the estimated
pulmonary artery systolic pressure is now lower.
CLINICAL IMPLICATIONS:
The patient has moderate mitral regurgitation. Based on [**2101**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 1 year.
DISCHARGE LABS [**2105-6-3**]:
WBC 10.3 HCT 25.7 (stable) Plt 504
Na 143 K 4.1 Cl 110 HCO3 23 BUN 20 Cr 1.5 Glc 78
Brief Hospital Course:
Ms. [**Known lastname 77625**] is a 73yo F with h/o CRI admitted with
tachycardia, anemia and hypocalcemia.
# Anemia: The patient had guaiac postive light brown stool on
arrival to the ICU, no known baseline HCT. The patient was
transfused 3 units pRBCs over the course of the hospitalization.
She underwent upper and lower endoscopy, which revealed an ulcer
in the incisura - the ulcer began bleeding after the first
endoclip was placed, so 2 more endoclips were placed afterward
with resolution of the bleeding. The colonoscopy revealed 4
polyps, which were removed. Also noted diverticula in the colon
- GIB most likely [**2-24**] to diverticulosis. Biopsy taken in the
stomach showed chronic inactive gastritis, no intestinal
metaplasia, and negative [**Doctor Last Name 6311**] stain. Biopsy of the colonic
polyps is still pending at the time of discharge. GI recommended
a repeat biopsy of the stomach ulcer when the patient is more
stable.
- f/u colon biopsies
- monitor HCT
- f/u scheduled with Atrius GI @ [**Location (un) **]
- H pylori eradication therapy as requested by GI
# Tachycardia: The patient was noted to be tachycardic to the
180s on admission. She had intermittent runs of SVT during the
first few days of hospitalization. TSH was WNL at 3.9. She
remained asymptomatic during the tachycardia and was
hemodynamically stable. She was started on Metoprolol and
Amiodarone with good effect - no further runs of SVT after the
Amiodarone was started. It was most likely due to cardiac
irritability in the setting of severe anemia and transient
cardiomyopathy (see below).
- f/u will be scheduled with Atrius cardiology
# Hypocalcemia: Unclear etiology, though given social stressors
and concern for possible depression may not have been having
reliable po intake. Additionally, she may have been using
magnesium citrate excessively as a laxative that could be
contributing to her electrolyte abnormalities (documented in
visit from PCP's office). PTH was noted to be markedly elevated
to 510. Vitamin D level was 22. Calcium was repleted several
times with Calcium gluconate IV. The patient was started on
Calcium carbonate 500mg PO TID and Vitamin D 800units daily.
Calcium on discharge was 8.3 (corrected for albumin 2.5).
# Acute on Chronic Renal Failure: Pt noted to have baseline
creatine ~1.5. Creatinine was elevated to 2.0 during the
hospitalization, likely due to profound anemia. Pt was also
noted to have a urinary tract infection, which was treated for a
7d course of Clindamycin. Creatinine improved to 1.5 (baseline)
at the time of discharge.
# Respiratory Distress: The patient developed respiratory
distress in the MICU, requiring intubation. Likely [**2-24**] to fluid
overload, as the patient improved quickly with diuresis. The
patient was weaned down to RA by the time she was transferred to
the floor. O2sats have remained in the high 90s on RA for the
remainder of the hospitalization.
# Leukocytosis: The patient was noted to have a leukocytosis,
WBC up to 26. She was found to have a Group B Strep UTI and was
treated for a 7d course with Clindamycin (allergy to PCN). The
WBC continued to climb for a few days after starting treatment -
however CXR was unremarkable, BCx were negative, and the patient
had no other localizing signs or symptoms. The WBC count started
to decline after several days of Clindamycin and was 10.3 on
discharge.
# AMS: The patient was delirious after extubation in the MICU
and was started on Olanzapine. She remained mildly confused for
several days after, with good improvement day to day. RPR, TSH,
B12, folate were all WNL. Only e/o infection was the UTI, as
above. The patient improved back to her baseline by the time of
discharge.
# PUMP: Initial TTE, in the setting of tachycardia, showed
moderately depressed LV systolic function, EF 30%. The patient
was fluid overloaded in the MICU, requiring intubation and
diuresis. Follow up ECHO a week later showed improvement -
normal LV systolic function, EF>55%. Moderate MR was noted, and
repeat ECHO in 1 year was recommended. Pt was started on a BB,
ACEi, and Lasix.
- repeat ECHO in 1 year
- stress test as outpatient
- has Atrius cards follow up scheduled
# Positive PAP: Family notified us of positive malignant cells
on recent PAP smear.
- GYN f/u scheduled for colposcopy
Medications on Admission:
Soothe Ophthalmic
Tylenol PM
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
Anemia
GI bleed
Supraventricular tachycardia
Urinary tract infection
Acute on chronic renal failure
Hypocalcemia
Altered mental status
Pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Hemodynamically stable.
Discharge Instructions:
Dear Ms. [**Known lastname 77625**],
.
You were admitted to the hospital with a low blood count and a
fast heart rate. Your rate heart is now being controlled with
new medications. Your low blood count was due to a bleeding
ulcer in your stomach - this was clipped by the
gastroenterologists, and there has been no further bleeding. You
were also found to have a urinary tract infection, and you
finished a course of antibiotics to treat this.
.
Your heart function was depressed, likely because of the low
blood count and the fast heart rate. This has now improved on
your repeat echocardiogram. You should have a stress test as an
outpatient to fully evaluate the function of your heart.
.
Please start taking all of the attached medications as
prescribed.
.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow up with your primary care physician 1-2 weeks
after discharge from rehab.
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Phone: [**Telephone/Fax (1) 3530**]
.
The following appointments have already been scheduled for you:
Specialty:Gastroenterology
Dr: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 86077**]
When: [**Last Name (LF) 2974**], [**6-19**] at 12pm
Where: [**Location (un) 2274**] [**Location (un) **], [**Location (un) 442**] Medical Specialties
Phone: [**Telephone/Fax (1) 2296**]
.
Specialty: Gynecology for a Colposcopy
Dr: [**First Name5 (NamePattern1) 333**] [**Last Name (NamePattern1) 86078**]
When: Wednesday, [**6-24**] at 1:20pm
Where: [**Location (un) 2274**] [**Location (un) **], [**Location (un) **] Gyn
Phone: [**Telephone/Fax (1) 86079**]
.
An appointment will be made for you to follow up with
Cardiology. Someone will call you with the date and time of the
appointment.
|
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47,435
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Discharge summary
|
report+addendum
|
Admission Date: [**2126-2-20**] Discharge Date: [**2126-2-27**]
Date of Birth: [**2052-4-29**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1945**]
Chief Complaint:
fall, hip fracture, humerus fracture
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Arterial line placement.
Surgical fixation of left intertrochanteric hip fracture using
trochanteric femoral nail.
Packed Red Blood Cell Transfusion (2 units)
History of Present Illness:
The patient is a 73 yo woman with h/o COPD, HTN, AFib on
Coumadin, who presented from home today after a mechanical fall.
Per the patient, she was walking to get her 3 PM medications and
tripped. She fell to the ground and hit a magazine rack. She did
not hit her head, and she did not lose consciousness. She called
for her husband, who immediately called EMS, and she was brought
to [**Hospital6 5016**] for further evaluation. XRays at [**Hospital 28941**] showed a left hip fracture and left humerus fracture. She
was thus transferred to [**Hospital1 18**] for orthopedic evaluation.
.
In the ED, the patient's initial VS were T 97.7, P 78, BP
126/84, R 18, O2 97% on 2L. She was given 1 L of NS and Dilaudid
2 mg IV. Ortho saw the patient in the ED, at which time she
desaturated to 90% on 2L. She had a CT Chest performed in the
ED, which did not show evidence of PE, and she had pelvic and
humerus XRays, which showed the fractures mentioned above. Her
VS at the time of transfer were T 97.6, P 85, BP 103/49, O2 93%
on 2L.
.
On the floor, the patient states that she feels dyspneic and
continues to have significant pain in her left arm and left hip.
On further questioning, she states that she is able to walk up
1.5 flights of stairs without stopping from shortness of breath.
She denies any recent history of chest pain and she states that
her activity is limited by osteoarthritis in her knees. She is
able to walk approximately 10 minutes on a flat surface.
.
Past Medical History:
Atrial Fibrillation
HTN
COPD
Mitral Valve Regurgiation
Hyperlipidemia
Osteoporosis
Social History:
The patient currently lives with her husband in an [**Hospital 4382**] facility. She previously worked in a law office but is
now retired. She currently smokes 1 ppd and drinks approximately
1 "cocktail" daily. She denies any history of alcohol
withdrawal.
Family History:
Her brother has low back pain and her mother and grandmother had
"heart disease."
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.4, BP: 136/100, P: 67, R: 20, O2: 93% on 2L
General: Elderly woman, appearing older than stated age. AAOx3
but with 3-word dyspnea. Visibly desatting to the high-80s with
conversation.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP ~ 11 cm, no LAD
Lungs: Diffuse expiratory wheezes in all lung fields anteriorly.
CV: Irregularly irregular. No murmurs, rubs, gallops
appreciated, but difficult to assess in the setting of diffuse
wheezing.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema bilaterally, dry skin, and skin darkening c/w chronic
venous stasis. LLE externally rotated and shortened. Large
ecchymoses on posterior aspect of LUE. LUE immobilized in a
sling.
Neuro: oriented x3, CNII-XII intact, no gross sensory or motor
deficits, negative pronator drift, gait not assessed
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
[**2126-2-19**] 11:10PM BLOOD WBC-13.0* RBC-4.13* Hgb-12.6 Hct-37.6
MCV-91 MCH-30.5 MCHC-33.6 RDW-13.9 Plt Ct-166
[**2126-2-19**] 11:10PM BLOOD Neuts-84.7* Lymphs-10.7* Monos-3.9
Eos-0.6 Baso-0.2
[**2126-2-19**] 11:10PM BLOOD PT-20.7* PTT-27.4 INR(PT)-1.9*
[**2126-2-19**] 11:10PM BLOOD Plt Ct-166
[**2126-2-19**] 11:10PM BLOOD Glucose-157* UreaN-24* Creat-0.9 Na-147*
K-4.1 Cl-110* HCO3-31 AnGap-10
[**2126-2-19**] 11:10PM BLOOD cTropnT-<0.01
[**2126-2-19**] 11:29PM BLOOD Glucose-149* K-4.1
IMAGING:
Left Humerus XRAY:
Patient positioning is suboptimal, with persistent
internal shoulder rotation and elbow flexion. No overt
glenohuymeral
dislocation. There is a comminuted fracture of the proximal
humeral diaphysis, with valgus angulation and anteromedial
displacement of the distal fracture fragment by approximately
one-half shaft width. Two intervening butterfly fragments are
rotated and laterally displaced by approximately 4 cm. Diffuse
overlying soft tissue swelling. No radiopaque foreign bodies are
identified. Visualized left lung normal. Markedly comminuted
and displaced fracture proximal humeral shaft.
Ab/Pelvic CT:
1. Mildly displaced comminuted intertrochanteric left femoral
fracture with surrounding hematoma and small left
femoroacetabular joint effusion.
2. Findings suspicious for nondisplaced sacral fracture.
Recommend
assessment with dedicated pelvic CT with attention to the
sacrum.
3. Free pelvic fluid.
CTA chest:
1. No evidence of acute intrathoracic process.
2. Moderate cardiomegaly.
3. Small ground glass nodule in the left upper lobe. If there
are risk
factors for malignancy such as smoking or a known prior history
of malignancy, the follow-up chest CT surveillance could be
considered in one year. Otherwise, follow-up is probably
unnecessary according to the [**Last Name (un) 8773**] society guidelines.
Intraoperative: 30 intraoperative radiographs of the left hip
were
obtained without radiologist present. A proximal gamma nail and
distal
interlocking screw are visualized.
Brief Hospital Course:
The patient is a 73 yo woman with h/o COPD, AFib, HTN, who
presented s/p mechanical fall with left hip and humerus
fracture, her brief hospital course is as follows:
.
# PELVIC AND HUMERAL FRACTURES: The patient had a mechanical
fall and sustained left-sided humeral and left comminuted
inter-and sub-trochanteric fractures. She was seen by orthopedic
surgery in the ED, who recommend surgery the following morning
for her femur, non-operative management of the arm. Per the
Revised [**Doctor Last Name **] cardiac risk index (RCRI), the patient had one
independent predictor of perioperative cardiac complications
(history of heart failure), so her risk of cardiac death,
nonfatal myocardial infarction, and nonfatal cardiac arrest was
approximately 1.0 percent (95% CI 0.5-1.4 percent). Based on
AHA/ACC guidelines, patient can tolerate > 4 METS of activity.
For intermediate risk surgery, she did not need further cardiac
testing prior to surgery and could proceed with orthopedic
surgery. Her pain was controlled prior to the surgery with
Tylenol RTC and Dilaudid 0.5 mg q3h prn. She had surgery on
[**2126-2-21**] for a fixation of left intertrochanteric hip fracture
using trochanteric femoral nail. She was placed in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8688**]
brace for her humerus fracture. Post surgically her pain was
controlled with standing tylenol, oxycodone and a lidoderm
patch. PT was consulted and saw the patient on the morning of
[**2-21**]. She was started on lovenox for post-surgical DVT ppx as
well as on her coumadin (her INR was reversed for the
procedure). Plan was for lovenox until she becomes therpeutic
on coumadin. She was also placed on calcium and vitamin D.
.
# HYPOXIA: Episodes of hypoxia were likely multi-factorial. In
the ED she appeared fluid overloaded on physical exam with 1+
edema bilaterally, orthopnea, hypoxia, and elevated JVD. She has
a history of mitral regurgitation and was given at least 1L of
NS in the ED. She currently takes Lasix 20 mg daily at home and
per report gets yearly TTEs by her PCP. [**Name10 (NameIs) **] was given lasix for
diuresis and supplemental oxygen and her hypoxia resolved
overnight. The following morning she was evaluated by our team,
anesthia and orthopedics. She was felt to be safe to go to the
OR on [**2126-2-21**]. The patient was transferred to the MICU from the
PACU after her ORIF due to difficulty weaning from the
ventilator. She was extubated shortly after she arrived in the
MICU was placed on NC. It was thought her difficulty with
extubation may have been from persistent sedation from the
procedure initially. She also has a history of COPD of unknown
severity which could have also contributed. Upon return to the
floor, her respiratory status normalized. She was continued on
her home spiriva and proair with supplemental oxygen as needed.
Patient was started on 20 MV i.v. lasix daily while on the floor
and improved with diuresis. Patient was transitioned to home
dose of PO lasix.
.
# HYPOTENSION: In the MICU, the patient had an A-line which read
persistently low SBPs. She was mentating and asymptomatic. Her
cuff pressures were higher and her A-line was pulled since it
did not appear to be a good tracing. She was dry on exam and
given 500 NS bolus and encourage po intake with stabilization of
her BP. Home antihypertensives were held. She did also get 1
unit PRBC intraoperatively. She also got 2 units of PRBC on [**2-22**]
on the floor for a low Hematocrit. She had one episode of low
SBP when gentle metoprolol was started for control of her afib,
however that resolved with gentle hydration. Patient was
eventually able to tolerate addition of metoprolol, lisinopril
(as substitute for Benazapril), and amlodipine. Patient was
discharged on home medication regimen.
.
# FEVER: She had a mild fever in the MICU which was possibly due
to post-op atalectasis. UA w/ bact, wbc, trace leuks, and
leukocytosis. Patient was asymptomatic. Blood cultures still
pending on discharge. Urine Culture with no growth.
.
# ANEMIA: She was given 1 unit pRBC intraoperatively, and 2
PRBCs postoperatively. Her hct was closely monitored and
remained stable throughout hospitalization.
.
# AFib: She is on metoprolol for rate control and she is on
coumadin at home at home for risk reduction. She was started on
lovenox (coumadin reversed for surgery). She was then bridged to
coumadin. Her metoprolol was restarted, however started at 25mg
TID for episodes of AFib with RVR. The patient remained rate
controlled throughout the rest of her hospital course.
.
# HTN: Her antihypertensives were initially held given
hypotensive episode in the ICU. Her metoprolol was restarted
first, gently for rate control. See above for addition of other
blood pressure medications.
.
# PROPHYLAXIS: She received lovenox and warfarin for dvt
prophylaxis. She received a bowel regimen for constipation
secondary to pain medicines. There was no clear indication for
GI prohphylaxis.
Medications on Admission:
Amlodipine 20 mg/Benazepril 5 mg daily
Evista 60 mg daily
Furosemide 40 mg daily
Metoprolol Tartrate 100 mg [**Hospital1 **]
Simvastatin 40 mg daily
Warfarin 4mg daily
Proair 2 puffs/day or prn
Spiriva 1 cap/day
Calcium with Vitamins
Glucosamine
Vitamin D3 2000U daily
Multivitamin
Krill Oil 1 cap daily
Discharge Medications:
1. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
5. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM. Tablet(s)
6. senna 8.6 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. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
10. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation once a day.
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. amlodipine-benazepril 5-20 mg Capsule Sig: One (1) Capsule
PO once a day.
13. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
14. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
hold for lightheadedness or low blood pressures. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary:
Left humerus fracture
Left intertrochanteric hip fracture
Secondary:
COPD
CHF
ANEMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted to the general medical service on [**2126-2-20**]
following a fall in your home. You broke your left upper arm
bone and your left hip. You had surgery on your hip on [**2126-2-21**]
with orthopedic surgery. After your surgery you spent one night
in the ICU because you had some difficult with breathing after
the surgery, you were then moved back to the general floor. You
received two units of blood via intravenous trasfusion because
of a low hematocrit. You were also given i.v. Lasix to help you
urinate out the fluid collecting in your lungs and legs. Your
symptoms improved with i.v. medication, and you were eventually
transitioned to your home regimen of oral medications, including
those for blood pressure. As you are transferred to a
rehabilitation facility, please continue all your home
medications.
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2126-2-28**] at 12:00 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2126-2-28**] at 12:20 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 14207**],[**Known firstname **] Unit No: [**Numeric Identifier 14208**]
Admission Date: [**2126-2-20**] Discharge Date: [**2126-2-27**]
Date of Birth: [**2052-4-29**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14209**]
Addendum:
The following are corrections to the discharge summary completed
above:
1.) Evista medication was d/ced. Patient was advised to stop
this medication as it is not primary line of treatment for
osteoporosis. Will follow up with PCP to consider starting
other agents, such as Alendronate.
2.) Coumadin was increased to 8 MG daily. Patient discharged on
this strength of medication.
3.) Patient discharged on lovenox until INR becomes therapeutic
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1933**]
[**First Name11 (Name Pattern1) 9188**] [**Last Name (NamePattern4) 14210**] MD [**MD Number(2) 14211**]
Completed by:[**2126-2-27**]
|
[
"458.29",
"812.09",
"820.21",
"401.1",
"428.23",
"998.12",
"564.09",
"820.22",
"518.0",
"276.2",
"424.1",
"427.31",
"287.5",
"285.1",
"518.5",
"493.20",
"V58.61",
"733.00",
"305.1",
"272.4",
"E878.1",
"E885.9",
"428.0",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15072, 15282
|
5631, 10630
|
341, 527
|
12575, 12575
|
3567, 3567
|
13650, 15049
|
2426, 2509
|
10985, 12366
|
12457, 12554
|
10656, 10962
|
12758, 13627
|
2549, 3521
|
265, 303
|
555, 2029
|
3583, 5608
|
12590, 12734
|
2051, 2136
|
2152, 2410
|
3548, 3548
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,255
| 171,115
|
41453
|
Discharge summary
|
report
|
Admission Date: [**2172-7-27**] Discharge Date: [**2172-8-5**]
Date of Birth: [**2105-3-24**] Sex: F
Service: SURGERY
Allergies:
No Known Drug Allergies / Lactose
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Lower GI Bleed
Major Surgical or Invasive Procedure:
[**2172-7-31**]: IVC Filter placement
History of Present Illness:
This is a 67 y/o female s/p OLT on [**2172-5-1**] for autoimmune
hepatitis, c/b by anterior abdominal wall necrosis, readmitted
on
[**2172-7-15**] for fevers and poor PO intake. On the previous
admission,
the patient had a klebsiella UTI, which was treated with
ciprofloxacin. In addition, she was found to have a right calf
DVT, in which coumadin was started. The patient was in her usual
state of health from [**7-21**] until 2 days ago, when she began to
have
dark, tarry stools. She had approximately [**3-24**] BM/day for the
past
2 days. She also complains of nausea and persistent poor PO
intake (which is her baseline and she has a Dobbhoff tube in
place for TF). Her hct last week was 31, now it is 25. Her INR
is
4.4. She received 10mg IV Vit K in the ED. The patient denies
headache, chest pain, SOB, chills/fever, and dysuria. However,
the patient does state dizziness on ambulating and persistent
right calf pain.
Past Medical History:
HLD
Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in
[**Male First Name (un) 1056**], complicated by varices
RA
DM2 with neuropathy
HTN, incl hypertensive nephropathy
B12 deficiency
Vitamin D Deficiency
Chronic pain syndrome - "colonic pain" per pt records
Colon polyps (hyperplastic and tubular adenoma)
Diverticulitis
Depression
PAD
s/p chole
s/p appy
s/p TAH/USO
Bladder prolapse repair
[**2172-5-1**] Liver transplant
[**2172-5-12**] ERCP, sphincterotomy, stent placement
Social History:
originally from [**Male First Name (un) 1056**]; has lived her with family for last
3 years. No etoh, illicits or tobacoo.
Family History:
non-contributory
Physical Exam:
T 97.7 HR 86 BP 108/42 RR 18 98% RA
GEN: NAD, AAOx3, no jaundice
HEENT: no scleral icterus, appears dry
CHEST: CTA B/L
HEART: RRR, S1, S2
ABD: soft, NT, Chevron incision with packing, no
rebound/guarding
Wound: opened Chevron incision with packing, good granulation
tissue, areas of exudate at the base of the wound, no drainage.
EXT: warm, no edema, R calf tender to palpation
Pertinent Results:
On Admission: [**2172-7-27**]
WBC-10.5 RBC-2.88* Hgb-8.7* Hct-24.9* MCV-87 MCH-30.4 MCHC-35.0
RDW-16.4* Plt Ct-268
PT-42.8* PTT-39.9* INR(PT)-4.4*
Glucose-184* UreaN-58* Creat-1.6* Na-134 K-4.8 Cl-96 HCO3-24
AnGap-19
ALT-15 AST-24 LD(LDH)-438* AlkPhos-113* TotBili-0.2
Albumin-3.3* Calcium-9.0 Phos-4.4 Mg-2.1 Iron-26*
TSH-7.4*
calTIBC-243 Ferritn-2504* TRF-187*
tacroFK-6.5
At Discharge: [**2172-8-4**]
WBC-5.1 RBC-3.36* Hgb-10.2* Hct-28.1* MCV-84 MCH-30.4 MCHC-36.3*
RDW-16.1* Plt Ct-182
PT-15.0* INR(PT)-1.3*
Glucose-201* UreaN-32* Creat-0.8 Na-139 K-3.2* Cl-106 HCO3-21*
AnGap-15
ALT-10 AST-19 AlkPhos-137* TotBili-0.3
Calcium-8.8 Phos-3.2 Mg-1.6
tacroFK-10.3
Brief Hospital Course:
67 y/o female admitted with melena and large number of stools
over last two days. Patient was initially admitted to the SICU
where she received 3 units of packed RBCs for a hct of 22.4. The
hct bumped appropriately and she did not require any more
transfusions.
Additionally the patient was noted to have an INR of 4.4 on
admission. She had received coumadin prior to her discharge 5
days prior. INR had been checked and lovenox d/c'd however the
INR became supertherapeutic. She was given 2 units FFP and
Vitamin K.
Fluconazole has been d/c'd.
Urine culture was obtained as she had been sent out on PO Cipro
with the last discharge. The new culture showed that the
Pseudomonas was now resistant to Cipro and she was started on IV
Cefepime. Another urien culture was obtained on [**8-1**] and the
Cefepime has now become resistant, and she was switched to IV
Ceftazadime. This will require long infusion times of 3 hours
each s the medication is Intermediate in sensitivity. Flagyl was
started empirically although C diffs have been negative.
Patient noted to have elevated creatinine upon admission. This
resolved with hydration, blood products and treatment of her UTI
nd she was back to better than baseline by day of discharge.
A PICC line has been placed for antibiotic infusion through
[**2172-8-10**].
On [**2172-7-31**], Dr [**Last Name (STitle) 1391**] took the patient to the OR for placement
of an IVC filter as it has been determined that anticoagulation
is not a safe option for this patient given recent GI bleeding.
The ultrasound done on admission on her legs showed
"Non-occlusive thrombus seen involving the distal right common
femoral vein and proximal right superficial femoral vein, right
posterior tibial veins, and left posterior tibial veins." The
right common femoral vein thrombus is new, the others were
existing prior and why the anticoagulation had been started. The
procedure was without complication.
The abdominal wound is healing. Initially the dressings were
changed [**Hospital1 **] as NS wet to dry dressings. There is good
granulation tissue and only a small amount of necrotic appearing
tissue at the apex. On Monday [**8-3**] a wound VAC was placed to the
wound to continue closure.
Tube feeds have been maintained via a post pyloric feeding tube.
Immunosuppression has been monitored throughout the admission.
Daily prograf levels have been done due to the fluconazole being
d/c'd. In addition she has been started on imuran 75 mg daily
due to her pre-op diagnosis of autoimmune hepatitis, and she
will stay on 5 mg prednisone with no further taper.
The patient has been very slow to be out of bed, with poor oral
intake. She stated to several caregivers that she feels
depressed, and concerned about how long she has been in the
hospital. Will benefit from more social work intervention.
Medications on Admission:
mycophenolate sodium 360 mg [**Hospital1 **], Tacrolimus 1mg [**Hospital1 **],
Ursodiol 300 mg TID, valganciclovir 450 mg TID, Vitamin D 800U
daily, amlodipine 10mg daily, ascorbic acid 500 mg [**Hospital1 **],
clonidine
0.1 mg daily, esomeprazole 40mg [**Hospital1 **], fluconazole 200 mg daily,
gabapentin 300mg [**Hospital1 **], regular insulin SS, metoprolol 37.5 mg
TID,
MVI daily, olanzapine 2.5 mg qHS, prednisone 2.5 mg daily,
sertraline 25 mg daily, Bactrim SS daily, Insulin glargine 12U
qHS, levothyroxine 25 mcg daily, ambien 5mg prn, loperamide 4mg
TID prn, ondansetron 4mg TID prn, Dilaudid prn
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. levothyroxine 50 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. azathioprine 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
15. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Do not taper.
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Lower
back.
18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: [**12-22**] Tablet, Chewables PO BID (2 times a day) as needed for
heartburn.
19. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
20. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
TID (3 times a day): Take 2 hours separately from
immunosuppression.
21. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for Empiric Cdiff: Through [**8-10**] unless
otherwise directed.
22. ceftazidime 2 gram Recon Soln Sig: Two (2) grams Injection
Q8H (every 8 hours) for 6 days: Please infuse dose over 3 hours
to maximize exposure (Intermediate sensitivity, all others
resistant) .
23. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Lower GI bleed
Supertherapeutic INR on Coumadin
Acute on chronic kidney failure (resolved)
UTI
Slow Abdominal wound healing
Malnutrition
Depression
Bilateral lower extremity DVT's s/p IVC filter placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, increased number of bowel movements,
dark or tarry stools, bright red blood per rectum, difficulties
with the tube feeds, dislodgement of feeding tube, increased
abdominal pain.
Please continue the VAC at 125 mm Hg continuous and change 3
times weekly per your facility protocol
Continue tube feeds (see nutrtion order)
Continue IV Ceftazadime via PICC line through [**2172-8-10**]. It is
mportant that the IV infusion be done over 3 hours to maximize
exposure as this medication is intermediate in sensitivity.
Plesae do not alter medications with consulting the transplant
clinic
Please courier labs to [**Hospital1 18**] with requisition every Monday and
Thursday
Followup Instructions:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**2172-8-12**]: 3:20 PM. Tel [**Telephone/Fax (1) 673**], [**Last Name (NamePattern1) 10357**], LMOB 7, [**Location (un) 86**], MA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2172-8-5**]
|
[
"787.91",
"584.9",
"709.8",
"599.0",
"311",
"266.2",
"250.60",
"780.62",
"453.51",
"E878.0",
"790.92",
"578.1",
"338.29",
"714.0",
"272.4",
"263.9",
"V58.67",
"V42.7",
"041.7",
"585.9",
"V09.91",
"403.90",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"88.51",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8879, 8951
|
3097, 5928
|
306, 345
|
9200, 9200
|
2409, 2409
|
10177, 10536
|
1974, 1992
|
6588, 8856
|
8972, 9179
|
5954, 6565
|
9383, 10154
|
2007, 2390
|
2798, 3074
|
252, 268
|
374, 1303
|
2423, 2784
|
9215, 9359
|
1325, 1817
|
1833, 1958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,993
| 148,288
|
51471
|
Discharge summary
|
report
|
Admission Date: [**2185-4-11**] Discharge Date: [**2185-4-21**]
Date of Birth: [**2116-4-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Small bowel resection
Second look laparotomy for ischemic bowel.
Primary anastomosis of jejunum to terminal ileum.
[**Last Name (un) **] gastrostomy.
Suture of multiple small bowel ischemic ulcerations
SMA stent
History of Present Illness:
69 yo male with h/o AAA repair presents with worsening abdominal
pain over the past few months that became severe one day prior
to admission. He has had significant weight loss and fear of
eating over the last few months because the pain is worse after
eating. He denies nausea and vomiting but does note some lose
stool. he denies any recent antibiotics use.
Past Medical History:
PMH:MI '[**66**], HTN, alcoholism, depression, 1ppd tobacco
PSH:AAA repair '[**73**]
Social History:
Heavy drinker, 1ppd tobacco
Family History:
NC
Physical Exam:
T99.1 HR99 BP 153/66 RR12 96% RA
GA: appears uncomfortable
HEENT: dry MMM sclera nonicteric
CV: rrr no m/r/g
Lungs: decreased breath sounds at bases
abd: mildly distended, soft, diffusely tender, rectal tone
normal brown heme positive stool.
extrem: no c/c/e
Pertinent Results:
[**2185-4-11**] 11:25AM WBC-30.6* RBC-5.17 HGB-15.9 HCT-45.3 MCV-88
MCH-30.8 MCHC-35.2* RDW-13.7
[**2185-4-11**] 11:25AM NEUTS-86.1* BANDS-0 LYMPHS-8.5* MONOS-4.8
EOS-0.4 BASOS-0.1
[**2185-4-11**] 11:25AM LIPASE-22
[**2185-4-11**] 11:25AM ALT(SGPT)-9 AST(SGOT)-30 ALK PHOS-148*
AMYLASE-28 TOT BILI-0.4
[**2185-4-11**] CTA: IMPRESSION:
1. Small bowel appearance concerning for partial small bowel
obstruction. Diffusely atherosclerotic superior mesenteric
artery and possible retrograde flow does raise the possibility
of underlying low-flow state and early mesenteric ischemia.
Close clinical correlation is recommended.
2. Bilateral hypodense lesions in the kidneys, most likely
consistent with simple renal cysts.
3. Compression fractures of T11 and L1 vertebral bodies.
4. Status post abdominal aortic aneurysmal appear.
CT abd: IMPRESSION:
1. Dilated loops of small bowel with air fluid levels and
decompressed distal large bowel could represent partial
small-bowel obstruction. With extensive atherosclerotic
calcified disease of the celiac and superior mesenteric artery,
a low-flow state is considered possible and thus there is
concern for mesenteric ischemia. Evaluation by intravenous
contrast to confirm patency of the major abdominal vessels is
recommended.
2. Atrophic pancreas.
3. Hypodense lesion of the right kidney is too small to
characterize but likely represents a simple renal cyst.
4. Unremarkable appearance of aortic abdominal aneurysm repair.
Path: Segment of ileum:
1. Hemorrhagic infarction, predominantly mucosal, with focal
transmural involvement.
2. Acute peritonitis.
3. The mucosal infarction extends to both margins
Brief Hospital Course:
Mr. [**Known lastname 31365**] was admitted to Dr.[**Name (NI) 12389**] service on [**2185-4-11**]. Based
on physical exam and CT results, the patient was found to have
mesenteric ischemia. He was taken to the OR on [**4-11**] and was found
to have small bowel necrosis requiring resection and stent
placement by [**Month/Day (2) 1106**] surgery. Please see operative reports for
further details. He was then transferred to the ICU with a plan
for a second look with or without anastomosis and definitive
abdominal closure.
POD1 Mr. [**Known lastname 31365**] was brought back to the OR. His remaining
bowel was well perfused with good pulse in the SMA. Small
ulcers were biopsied and he underwent a primary anastomosis of
jejunum to terminal ileum without complications. Please see
operative note from [**2185-4-12**] for further details. The patient
remained intubated in the ICU. On POD2/1 the patient was
successfully extubated and his pain was controlled with a
Dilaudid PCA. He remained somewhat confused but his neurologic
exam was intact. POD3/2 the patient was started on tube feeds
which were tolerated. His mental status continued to clear and
his pain was well controlled. He was transition ed to PO pain
medications without difficulty. He was started on a regular diet
on POD [**7-17**] and tolerated it well.
The pathology results returned confirming ischemic ileum.
Mr. [**Known lastname 31365**] remained afebrile and without abdominal pain. He
completed a course of Levaquin and Flagyl and his white blood
cell count decreased. He was seen by PT and OT who recommended
rehab for balance, gait, and strengthening.
He was discharged home to rehab with cycled TF and
tolerating a regular diet. He will follow up with the [**Known lastname 1106**]
surgeon and Dr. [**Last Name (STitle) **] and his GI physician.
Medications on Admission:
oxycodone, temazepam, omeprazol, ativan, lipitor, toprolol
[**Last Name (LF) 8864**],[**First Name3 (LF) **]
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**First Name3 (LF) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Aspirin 325 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO DAILY (Daily).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**First Name3 (LF) **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg Tablet [**First Name3 (LF) **]: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
5. Acetaminophen 325 mg Tablet [**First Name3 (LF) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Do not exceed 4 grams of Acetaminophen
per day when also giving Percocet.
6. Metoprolol Tartrate 50 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO TID
(3 times a day).
7. Clonidine 0.2 mg/24 hr Patch Weekly [**First Name3 (LF) **]: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Psyllium 1.7 g Wafer [**Last Name (STitle) **]: [**1-11**] Wafers PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection twice a day.
12. Lipitor 80 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 18346**]
Discharge Diagnosis:
Primary: Mesenteric ischemia s/p SMA stent, small bowel
resection with primary reanastamosis
Secondary: HTN
s/p MI
alcoholism
depression
s/p AAA repair
Discharge Condition:
stable
Discharge Instructions:
Please take your medications as directed. No heavy lifting
greater than 10lbs.
Call your doctor or go to the ED for:
-fever>102
-chest pain or shortness of breath
-abdominal pain or significant blood in your stool
-or any other concerning symptoms.
Followup Instructions:
Follow up with Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY
(NHB) Date/Time:[**2185-5-12**] 11:00; tel # [**Telephone/Fax (1) 2625**].
Please call Dr.[**Name (NI) 12389**] office for a follow up appointment in
[**2-12**] weeks [**Telephone/Fax (1) 68386**]
Completed by:[**2185-4-21**]
|
[
"291.81",
"569.82",
"557.0",
"276.2",
"401.9",
"303.90",
"787.91",
"V45.82",
"567.29",
"557.1",
"412",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"39.50",
"46.73",
"00.45",
"43.19",
"45.91",
"96.6",
"00.40",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
6477, 6525
|
3094, 4934
|
328, 542
|
6721, 6730
|
1400, 3071
|
7028, 7408
|
1101, 1105
|
5093, 6454
|
6546, 6700
|
4960, 5070
|
6754, 7005
|
1120, 1381
|
274, 290
|
570, 931
|
953, 1040
|
1056, 1085
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,610
| 152,224
|
1061+55257
|
Discharge summary
|
report+addendum
|
[** **] Date: [**2197-6-25**] Discharge Date: [**2197-6-28**]
Date of Birth: [**2130-9-22**] Sex: M
Service: MEDICINE
Allergies:
Anticholinergics,Other / Eldepryl / Amitriptyline / Cogentin /
Paxil
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Falls
Major Surgical or Invasive Procedure:
RIJ placement
History of Present Illness:
66 yo man from NH with h/o parkinson's disease s/p deep brain
stimulation presented from [**Hospital3 **] s/p fall x 3 in last
2 days. Struck head with one fall (transitioning from wheelchair
to chair) hit his head on carpet. Some dysuria, no fevers, some
SOB. No HA, no LOC, no seizures, no weakness/pain.
.
In the ED, initial vs were: T 99.5 HR74 BP149/79 RR18 O2Sat97.
Then spiked to 100.5. Was given APAP. UA positive with
leukocytosis. Patient was given cipro, levophed for five minutes
but developed CP while he was on it so it was discontinued.
While in ED had afib with RVR with rate in 140s. Now 120s.
Hypotensive to SBP80s with that HR. RIJ CVL was placed. CXR
pending. EKG without changes per ED physician. [**Name10 (NameIs) **] to unit
for hypotension/tachycardia.
.
VS: HRs 107-110s, BP101/83, RR 30 O2Sat:94% on 2L NC
.
On the floor, patient had some low back pain initially when
getting situated in bed but this resolved quickly. Otherwise he
had no complaints specifically no complaints of SOB, chest pain,
dizziness, palpitations.
Past Medical History:
# Parkinsons disease X 17 years s/p deep brain stimulation [**2190**]
followed by Dr. [**First Name (STitle) **]
# Chronic LBP
# SSS (aflutter with severe bradycardia) s/p [**Company 1543**] Sigma
dual-chamber pacemaker followed by Dr. [**Last Name (STitle) **]
# Superficial thrombophlebitis [**5-13**] treated briefly with lovenox
# HTN
# Obesity
Social History:
Retired. Multiple jobs before. He currently resides at [**Location (un) 6927**] Rest Home ([**Hospital3 **]). They administer his meds
to him. He denies tobacco or alcohol use. Walks with a walker
[**3-7**] parkinsons disease.
Family History:
Great Aunt with Parkinson's Disease. Daughter and son are
healthy.
Physical Exam:
General: Alert, oriented, no acute distress, masked facies
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irRegular rhythm, tachycardic normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema bruising on right lateral calf
Neuro: A+OX3
Pertinent Results:
CXR [**2197-6-25**]: FINDINGS: Bilateral neural stimulators project over
the lower chest. A pacer unit projects over the right upper
chest with leads in the right atrium and right ventricle. The
cardiomediastinal silhouette appears unremarkable. The aorta
takes a tortuous course. The lungs are clear of masses or
consolidations. The hila are normal appearing bilaterally. There
is no pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
.
NCHCT [**2197-6-25**]: FINDINGS: Bilateral deep brain stimulation leads,
terminating within a subthalamic region, are unchanged in
position or appearance from [**2196-11-21**]. Associated streak
artifact limits evaluation. No intracranial hemorrhage, edema,
shift of normally midline structures, or acute major vascular
territorial infarction is identified. Minimal periventricular
white matter low attenuation is most compatible with chronic
small vessel ischemic disease. Ventricles and sulci are
prominent, likely reflective of age-related atrophy. Visualized
paranasal sinuses and mastoid air cells are normally aerated.
Osseous structures reveal no evidence of fracture.
IMPRESSION:
1. No acute intracranial process.
2. Stable appearance of bilateral deep brain stimulator leads.
.
[**Year (4 digits) **] Labs
[**2197-6-25**] 11:25AM WBC-16.2*# RBC-4.52* HGB-14.5 HCT-43.6 MCV-96
MCH-32.1* MCHC-33.3 RDW-13.6
[**2197-6-25**] 11:25AM NEUTS-89.7* LYMPHS-4.6* MONOS-4.7 EOS-0.4
BASOS-0.5
[**2197-6-25**] 12:00PM URINE BLOOD-LG NITRITE-POS PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2197-6-25**] 12:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2197-6-25**] 12:28PM LACTATE-1.0
[**2197-6-25**] 08:30PM CK-MB-NotDone cTropnT-<0.01
.
Discharge Labs:
[**2197-6-27**] 05:38AM BLOOD WBC-9.0 RBC-4.10* Hgb-13.2* Hct-39.5*
MCV-96 MCH-32.2* MCHC-33.5 RDW-13.7 Plt Ct-194
[**2197-6-28**] 05:10AM BLOOD Glucose-102* UreaN-11 Creat-0.6 Na-138
K-3.6 Cl-101 HCO3-30 AnGap-11
Brief Hospital Course:
66yo M with h/o parkinson's disease, SSS s/p pacemaker, and
recent superficial thrombophlebitis now admitted with
hypotension likely [**3-7**] urosepsis.
.
# Hypotension: With floridly positive UA and leukocytosis could
have urosepsis although other etiologies including cardiac more
likely given that lactate was negative and he was hypotensive in
the setting of AF with RVR. Also, hypotension resolved with
resolution of RVR. He was monitored overnight in the ICU and
given metoprolol for rate control. His BP remained within
normal limits throughout the rest of his stay. His lisinopril
was held in the setting of hypotension and restarted prior to
discharge. The patients Metoprolol was uptritrated from 25mg [**Hospital1 **]
to 50mg TID.
.
# AFib with RVR: His RVR responded to metoprolol and his BP
stabilized. He converted to sinus on the morning after
[**Hospital1 **] with HR in control. He was continued on aspirin 325mg
(unclear reason for 81mg TID at home). His Metoprolol was
increased to 50mg TID from 25mg [**Hospital1 **].
.
# UTI: UA returned positive and UCx grew quinolone sensitive
ecoli, sensitivities pending. BCx pending x 2 from [**6-25**]. He
was given cipro and was discharged for a total course of 14
days.
.
# RBBB: Likely age-related conduction delay in setting of
tachycardia. Last EKG in system is [**2190**] so may have had this for
a long time. PE very unlikely given not hypoxic with no acute
respiratory complaints. His EKG was rechecked after sinus
conversion and the RBBB remained. He had cardiac enzymes
negative x 3.
.
# Falls: Patient has had several falls at the [**Hospital3 **]
which was the initial presenting complaint. Possibly [**3-7**]
parkinson's disease with poor balance at baseline per notes in
OMR and patient history with new UTI and possibly af with RVR at
home. His celexa was held as a possible contributing factor.
.
# Parkinsons: Recently saw neurology who made no changes to his
regimen.
- Continue on his home regimen of carbi/levadopa
- Per renal dosing can get [**Hospital1 **] amantidine here (gets TID at
home) as renal function improves can increase dose
- Email Dr. [**First Name (STitle) **] re: whether celexa could contribute to
worsening parkinsons/falls
.
# Chronic LBP: Continued on home regimen of gabapentin and
motrin. Additionally, he was started on a lidocaine patch with
improved pain control.
.
# h/o HTN: As patient initially hypotensive, his lisinopril was
held. Beta blocker was titrated up as noted above. After
transfer out of the ICU, the patient became hypertensive and his
beta blocker was titrated up to 50 mg TID and lisinopril was
restarted with improved BP control.
# Communication: Patient and son [**Name (NI) 915**] [**Telephone/Fax (1) 6928**]
.
The patients rehabilitation in anticipated to be less than 30
days
Medications on [**Telephone/Fax (1) **]:
(per [**Hospital3 **] records)
Ibuprofen 400mg [**Hospital1 **] with food
AMANTADINE - (Dose adjustment - no new Rx) - 100 mg Capsule - 1
Capsule(s) by mouth three times a day
CARBIDOPA-LEVODOPA - 25 mg-100mg Tablet - 3 tabs between 2am and
4am PRN per patient request and 3 tabs 4 times daily (9a, 3p,
9p, 12a)CITALOPRAM - 20 mg by mouth at bedtime
GABAPENTIN 300 mg [**Hospital1 **] an 900mg QHS
LISINOPRIL 30 mg Tablet by mouth once a day
METOPROLOL TARTRATE 25 mg by mouth twice daily
OMEPRAZOLE - 20 mg Capsule by mouth once a day
Lactulose 30mL daily
senna 1 tab daily
Colace 1 tab twice daily
ASPIRIN 81mg by mouth three times a day
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Pain.
4. Amantadine 100 mg Capsule Sig: One (1) Capsule PO three times
a day.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
- Urinary Tract Infection
- Sepsis
- Atrial Fibrillation in RVR
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for falls and found to have a
urinary tract infection. You were initially admitted to the ICU
because of low blood pressure and elevated heart rate. You were
treated with IV fluids and antibiotics and your symptoms
improved.
.
We made the following changes to your home medications:
-START Cipro for 10 days
-STOP Celexa
-INCREASE metoprolol to 50mg Three Times Daily
-Start Lidocaine Patch 5%
Followup Instructions:
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2197-6-29**] at 11:30 AM
With: MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Department: NEUROLOGY
When: MONDAY [**2197-7-24**] at 9:00 AM
With: [**Name6 (MD) 3557**] [**Name8 (MD) 3558**], MD [**Telephone/Fax (1) 44**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: NEUROLOGY
When: MONDAY [**2197-7-24**] at 9:00 AM
With: [**Name6 (MD) 3557**] [**Name8 (MD) 3558**], MD [**Telephone/Fax (1) 44**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: DERMATOLOGY
When: FRIDAY [**2197-8-4**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2197-7-24**] at 9:00 AM
With: [**Name6 (MD) 3557**] [**Name8 (MD) 3558**], MD [**Telephone/Fax (1) 44**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Name: [**Known lastname **] [**Last Name (LF) 875**],[**Known firstname **] E Unit No: [**Numeric Identifier 876**]
Admission Date: [**2197-6-25**] Discharge Date: [**2197-6-28**]
Date of Birth: [**2130-9-22**] Sex: M
Service: MEDICINE
Allergies:
Anticholinergics,Other / Eldepryl / Amitriptyline / Cogentin /
Paxil
Attending:[**First Name3 (LF) 877**]
Addendum:
On discharge, patient's BP was 98/58, HR 86.Patient was
asymptomatic, and decreased BP felt to be secondary to
uptitration of metoprolol. Consequently, paperwork was changed
so that patient should be administered metoprolol 50 mg [**Hospital1 **]
rather than TID. His blood pressure should continue to be
monitored daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 163**] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 878**] MD, [**MD Number(3) 879**]
Completed by:[**2197-6-28**]
|
[
"401.9",
"300.4",
"V12.52",
"590.10",
"427.81",
"426.4",
"356.9",
"724.2",
"458.29",
"E942.6",
"427.31",
"427.32",
"038.9",
"V45.89",
"995.91",
"278.00",
"332.0",
"V45.01",
"V15.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13120, 13348
|
4741, 8249
|
332, 347
|
10105, 10105
|
2712, 4487
|
10742, 13097
|
2061, 2129
|
8272, 9867
|
9984, 10084
|
10288, 10589
|
4503, 4718
|
2144, 2693
|
10607, 10719
|
287, 294
|
375, 1426
|
10120, 10264
|
1448, 1800
|
1816, 2045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,657
| 169,263
|
13518
|
Discharge summary
|
report
|
Admission Date: [**2145-3-21**] Discharge Date: [**2145-3-24**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Shortness of breath, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
32 y/o M with hx of DM I, HTN, ESRD on HD (last HD yesterday
with uneventful full run). Today had sudden onset SOB when he
woke up. Felt positional and was improved with sitting up and
worsened with lying down. Also then had symptoms with diarrhea
and vomiting a few hours after waking up. They were
non-bilious, non-bloody emesis and diarrhea. His SOB continued
and he felt as if he had a tight feeling in his chest. Also
felt some tightness substernally. No fevers, chills. Did have
some sweats recently, but had otherwise been feeling well and
healthy since his last discharge for n/v and gastroparesis.
.
In the ED, initial vitals were T 100.4, 203/116, 114 NSR, 40,
85% RA. Overall, mildly uncomfortable and working to breath,
rales bilaterally. Had soft, distended, non-tender abdomen.
Refused guiac exam. He received vanco, zosyn, and levo for
potential pna. Also received an ASA. Started on nitro gtt for
hypertension. Renal aware of patient and that he received
contrast for his CTA.
.
On transfer from the ED, his vitals were 181/107, 124, 25, 97%
NRB (was 90 on 6L). He was mildly uncomfortable. He is
complaining of shortness of breath and a headache. His nausea
is mostly improved. He otherwise is comfortable on 6L NC.
.
In the MICU, he had CTA which was negative for PE and consistent
with pulmonary edema so antibiotics were discontinued. He
received a one time dose of lasix 20 IV with good UOP and BP
improved on home regimen as he was weaned off nitro drip and
down to 2L O2 by NC. At time of transfer, he reports SOB much
improved and denies any current CP.
Past Medical History:
- HTN
- DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy,
gastroparesis, and possibly retinopathy.
- CKD: thought to be related to HTN and longstanding diabetes.
Now on hemodialysis T/Th/Sat. Does make urine. Has been listed
on kidney/pancreas transplant wait list since 4/[**2144**].
- Anemia: Thought to be combination of iron deficiency and CKD,
now on epo with dialysis
- Depression
- s/p appendectomy [**7-/2144**]
Social History:
States that he previously drank heavily (30-40 drinks/week) but
has not used alcohol since [**2144-11-14**]. +h/o tobacco use, quit in
[**2142**], relapsed, quit last year and denies tobacco currently.
Denies other drugs. Neg PPD [**2145-2-26**]. Lives with girlfriend.
Family History:
No FH of pancreatitis. Diabetes and heart trouble in
grandfather.
Physical Exam:
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), no rubs
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , Crackles : few at bilateral bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
[**2145-3-21**] 07:00PM BLOOD WBC-8.1 RBC-3.05* Hgb-8.4* Hct-27.1*
MCV-89 MCH-27.5 MCHC-31.0 RDW-15.3 Plt Ct-275
[**2145-3-22**] 04:02AM BLOOD WBC-9.3 RBC-2.64* Hgb-7.4* Hct-23.7*
MCV-90 MCH-28.1 MCHC-31.3 RDW-15.4 Plt Ct-282
[**2145-3-23**] 07:20AM BLOOD WBC-10.4 RBC-2.74* Hgb-8.1* Hct-24.7*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.8* Plt Ct-312
[**2145-3-24**] 06:03AM BLOOD WBC-5.1# RBC-2.65* Hgb-7.9* Hct-24.1*
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.6* Plt Ct-252
[**2145-3-21**] 07:00PM BLOOD Neuts-86.7* Lymphs-9.3* Monos-3.7 Eos-0.3
Baso-0.1
[**2145-3-22**] 04:02AM BLOOD PT-11.8 PTT-26.0 INR(PT)-1.0
[**2145-3-21**] 07:00PM BLOOD Glucose-214* UreaN-23* Creat-6.4*# Na-137
K-5.5* Cl-99 HCO3-30 AnGap-14
[**2145-3-22**] 04:02AM BLOOD Glucose-91 UreaN-27* Creat-7.3* Na-138
K-4.6 Cl-101 HCO3-30 AnGap-12
[**2145-3-23**] 07:20AM BLOOD Glucose-127* UreaN-36* Creat-9.3*# Na-135
K-6.1* Cl-97 HCO3-26 AnGap-18
[**2145-3-24**] 06:03AM BLOOD Glucose-177* UreaN-26* Creat-7.0*# Na-134
K-4.9 Cl-95* HCO3-31 AnGap-13
[**2145-3-21**] 07:00PM BLOOD ALT-77* AST-71* AlkPhos-93 TotBili-0.3
[**2145-3-22**] 04:02AM BLOOD ALT-57* AST-39 CK(CPK)-261 AlkPhos-80
TotBili-0.3
[**2145-3-23**] 07:20AM BLOOD ALT-44* AST-25 AlkPhos-90 TotBili-0.4
[**2145-3-24**] 06:03AM BLOOD ALT-33 AST-21 AlkPhos-78 TotBili-0.2
[**2145-3-21**] 07:00PM BLOOD Lipase-177*
[**2145-3-21**] 07:00PM BLOOD proBNP-[**Numeric Identifier 40887**]*
[**2145-3-21**] 07:00PM BLOOD cTropnT-0.10*
[**2145-3-22**] 04:02AM BLOOD CK-MB-2 cTropnT-0.12*
[**2145-3-22**] 12:10PM BLOOD CK-MB-2 cTropnT-0.12*
[**2145-3-22**] 04:02AM BLOOD Calcium-8.6 Phos-2.2*# Mg-1.6
[**2145-3-23**] 07:20AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.7
[**2145-3-24**] 06:03AM BLOOD Calcium-8.3* Phos-4.5# Mg-1.6
[**2145-3-21**] 7:00 pm BLOOD CULTURE LINE EJ: Pending at
discharge.
URINE CULTURE (Final [**2145-3-23**]): NO GROWTH.
Legionella Urinary Antigen (Final [**2145-3-22**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
--
Radiology Report CHEST (PORTABLE AP) Study Date of [**2145-3-21**]
Final Report
EXAM: Chest frontal, single AP upright portable view.
Large areas of airspace opacity involving the right mid-to-lower
lung, likely involving the right middle and lower lobes and
possibly the right upper lobe. There is suggestion of small
bilateral pleural effusions. The cardiac silhouette remains
enlarged.
IMPRESSION:
1. Right lung airspace opacity concerning for infectious process
vs edema. Recommend clinical correlation and followup to
resolution. Small bilateral pleural effusions.
2. Persistent moderate cardiomegaly.
---
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2145-3-21**] Final Report
CHEST CT WITH IV CONTRAST: The thoracic aorta is normal in
course and
caliber, without dissection. The pulmonary arteries opacify
normally, without evidence of pulmonary embolism. The main
pulmonary artery is enlarged, measuring 3.6 cm in diameter.
Mediastinal and hilar lymph nodes do not meet size criteria for
pathologic enlargement. There are extensive nodular opacities
involving all lobes of the lungs, mid lung and basal
predominant. More confluent areas of airspace consolidation are
present centrally and dependently. There is interlobular septal
thickening, left greater than right. The airways are patent
bilaterally to the subsegmental level. There is a small right
pleural effusion and a moderate pericardial effusion. The heart
is enlarged. Enlarged prevascular and pretracheal mediastinal
lymph nodes are likely reactive. Anterior mediastinal soft
tissue density is likely residual thymus.
Imaging of the upper abdomen is unremarkable. There are no
concerning osseous lesions.
IMPRESSION:
1. No pulmonary embolism. No aortic dissection.
2. Extensive nodular opacities throughout all lobes concerning
for infection. Confluent areas of airspace opacity may reflect
pulmonary edema or infection. Septal thickening consistent with
interstitial pulmonary edema. Mediastinal lymphadenopathy, may
be reactive.
3. Moderate pericardial effusion.
4. Small right pleural effusion.
5. Enlarged main pulmonary artery suggestive of pulmonary
arterial
hypertension.
---
Portable TTE (Complete) Done [**2145-3-22**] at 9:30:00 AM FINAL
Findings
This study was compared to the prior study of [**2144-2-14**].
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Low
normal LVEF. Estimated cardiac index is normal (>=2.5L/min/m2).
No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta. No 2D or Doppler evidence of distal arch coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Small to moderate pericardial effusion. Effusion
circumferential. No echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is low normal. Quantitative
biplane LVEF is 52%. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is moderate pulmonary artery
systolic hypertension. There is a small to moderate sized
circumferential pericardial effusion without echocardiographic
signs of tamponade. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
IMPRESSION: Mild symmetric left ventricular hypertrophy with low
normal systolic function. Moderate pulmonary artery systolic
hypertension. Small-moderate circumferential pericardial
effusion.
Compared with the prior study (images reviewed) of [**2144-2-14**],
left ventricular systolic function is less vigorous and
pulmonary artery systolic hypertension is now identified.
CLINICAL IMPLICATIONS:
Based on [**2142**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
---
Radiology Report CHEST (PORTABLE AP) Study Date of [**2145-3-22**]
Final Report
PORTABLE CHEST
FINDINGS: Previously identified asymmetrically distributed
opacities in the right lung have rapidly improved with only
minimal residual opacities,
predominantly in the right retrocardiac region. However, opacity
in the left retrocardiac area has slightly worsened. Small
pleural effusions are again demonstrated. Cardiac silhouette
remains enlarged and there is persistent increase in pulmonary
vascularity.
IMPRESSION:
1. Rapid improvement in right-sided alveolar opacities, which
may have been due to asymmetrical pulmonary edema or aspiration
considering the rapid improvement. Worsening opacities at left
base could reflect evolving
infection in the appropriate clinical setting.
2. Enlarged cardiac silhouette with known pericardial effusion.
3. Small bilateral pleural effusions.
--
Radiology Report CHEST (PA & LAT) Study Date of [**2145-3-23**]
Final Report
IMPRESSION: PA and lateral chest compared to [**3-22**]:
Severe cardiomegaly is stable. Small left pleural effusion is
new or newly
apparent. Pulmonary vascular congestion is mild though the upper
lobe vessels are clearly dilated and there is no pulmonary
edema.
--
Brief Hospital Course:
32yom w T1DM, ESRD on hemodialysis, HTN presented with sudden
onset dyspnea, likely due to flash pulmonary edema in setting of
severe hypertension.
# Shortness of breath: Presented w sudden onset dyspnea. Most
likely due to flash pulmonary edema given severe HTN on
presentation, elevated BNP, CXR and CTA showing pulmonary edema
which rapidly resolved with blood pressure control. Echo showed
new findings of mild LV systolic dysfunction (EF 52%), moderate
pulmonary artery HTN, and small-moderate circumferential
pericardial effusion (previously seen on CT abd [**2145-3-6**]).
Troponins cycled every 8 hours were 0.10, 0.12, 0.12, consistent
with demand ischemia in setting of renal failure without concern
for an acute ischemic event. EKG on admission was unchanged from
prior. CTA was negative for PE. Initially, CXR had infiltrate
concerning for PNA, so pt was started on antibiotics for
hospital acquired PNA. However, these were discontinued after
rapid improvement of CXR with diuresis. In the MICU, pt was
treated with a nitro drip, lasix (with good urine output), and
supplmental O2 via nasal cannula. On transfer to the floor,
lungs were wheezy and pt sated 91%-95% on 2-4L NC. After
hemodialysis, lungs were clear, and pt sated 95-100% on room
air. Although patient had low grade temperatures (99.0), he did
not develop localizing symptoms or leukocytosis concerning for
health care acquired pneumonia. Given good urine output despite
being on hemodialysis, patient was started on 80mg daily of
Lasix PO by Renal upon discharge.
.
# Hypertension: SBP in 200s on arrival in setting of medication
noncompliance secondary to PO intolerance. Placed on nitro drip
until tolerating POs, at which point home antihypertensives
(hydralazine, lisinopril, metoprolol) were restarted. SBP ranged
120s-170s on floor with some improvement after dialysis as well.
.
# End stage renal failure: Renal followed patient, and he was
able to remain on his regular T/Th/Sat dialysis schedule while
in house.
.
# Nausea/Vomiting: Etiology for nausea and vomiting unclear,
although likely from gastroparesis as noted in previous
admissions. Was given zofran and reglan PRN with good control of
symptoms.
.
# Pulmonary Hypertension: Increased PASP new since last TTE and
slightly decreased LVEF compared with 2/09 as well as BNP [**Numeric Identifier 14123**]
all suggest left heart failure as etiology of pulmonary
hypertension. Patient should consider further work-up as
outpatient (rheum, LFTs, HIV, right heart cath...)
.
# Pericardial Effusion: likely secondary to renal failure.
Unchanged based on findings on CT scan. Pulsus < 10 without
signs of tamponade.
.
# Anemia: On transfer to MICU, Hct was 27, which was above
baseline of 23. Thought to be secondary to volume contraction in
the setting of nause and vomiting. With improvement of
nausea/vomiting his hematocrit trended back to his baseline of
23. No clinical evidence of bleeding during his stay.
.
# Transaminitis: On admission, mildly elevated AST and ALT in
70s. Alk phos was normal. Unclear etiology, but perhaps
secondary to hepatic congestion in setting of flash pulmonary
edema. Had normal ultrasound last admission. Liver function
tests were trended and came down with improvement in his
clinical status.
.
# Type I Diabetes: Complicated by nephropathy, neuropathy and
gastroparesis. Remained on insulin sliding scale and home lantus
dose. Blood sugar ranged from 161-204. No anion gap on routine
labs to suggest ketoacidosis.
Medications on Admission:
# Hydralazine 25 mg tabs, 1-2 tabs TID
# Amlodipine 10 mg daily
# Calcium Acetate 667 mg TID
# Vitamin D 5,000 units daily
# Calcitriol 0.25 mcg daily
# Metoclopramide 5 mg TID PRN
# Lisinopril 20 mg daily
# Metoprolol Succinate 200 mg Tablet Sustained Release daily
# EMLA 2.5-2.5 % Cream [**Hospital1 **]
# Humalog Sliding Scale
# Glargine 15 u qHS
Discharge Medications:
1. Hydralazine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Metoclopramide 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day): Do not take when you have loose stools, diarrhea.
5. Vitamin D 5,000 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a day
for 2 weeks.
6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1)
Capsule PO once a week: Mondays.
7. Calcitriol 0.25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO once a
day.
8. Amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
[**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Lasix 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Fifteen (15)
units Subcutaneous with breakfast.
12. Humalog 100 unit/mL Solution [**Hospital1 **]: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Flash pulmonary edema with hypertensive urgency
Secondary: ESRD on hemodialysis, type 1 diabetes mellitus,
gastroparesis, anemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
-You were admitted with acute shortness of breath, nausea and
vomiting. You likely had an episode of "flash pulmonary edema,"
or rapid fluid buildup in the lungs, due to high blood pressures
(perhaps from high sodium/salt meal). Your blood pressure was
aggressively controlled; fluid in your lungs was removed by
hemodialysis and a water pill (Lasix) with improvement in your
breathing.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> Start Lasix 80mg daily
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please make an appointment to see your primary care doctor
within 2 weeks. You can reach Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40888**] office at
[**Telephone/Fax (1) 250**].
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2145-3-24**] at 12:00 PM
With: [**First Name8 (NamePattern2) 971**] [**Last Name (NamePattern1) **], LICSW [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT
When: MONDAY [**2145-4-12**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2145-4-16**] at 3:00 PM
With: [**Year (4 digits) **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"362.01",
"536.3",
"423.9",
"280.9",
"250.51",
"428.0",
"250.41",
"428.31",
"V45.89",
"311",
"V58.67",
"790.4",
"403.01",
"250.61",
"585.6",
"416.8",
"583.81",
"285.21",
"V45.11",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16900, 16906
|
11614, 15113
|
336, 343
|
17088, 17088
|
3491, 10099
|
18037, 19267
|
2747, 2815
|
15514, 16877
|
16927, 17067
|
15139, 15491
|
17236, 18014
|
2830, 3472
|
10122, 11591
|
259, 298
|
371, 1968
|
17103, 17212
|
1990, 2441
|
2457, 2731
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,510
| 162,165
|
38285
|
Discharge summary
|
report
|
Admission Date: [**2188-7-26**] Discharge Date: [**2188-7-29**]
Date of Birth: [**2136-11-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
EtOH Withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 80827**] is a 51 yo F w/ h/o ETOH abuse, DM2 who presented
to our ED from OSH with a depressed temporal skull fx with small
amt of pneumocephalus.
Of note, the pt remembers falling about 2 wks ago under the
influence of ETOH but treating this at home and not seeking
medical attention. On the day of admission, she noted the area
to start bleeding again without provokation and called EMS. On
EMS arrival, she states she was frightened and went running out
to meet EMS when she syncopized without striking her head. At
the OSH, she had a CT head which showed L temporal depressed
skull fx with a small areaof pneumocephalus. There, she recieved
1g IV ancef and was transfered to [**Hospital1 18**].
Neurosurgery was consulted from our ED who stated this fracture
looked old and recommended 10D of keflex and D/c home. Her C
spine was also cleared by them as well. She was observed
overnight in ED (o/n she got albuterol, tylenol for unclear
reasons, KCL, thiamine, folate, ibuprofen) and was going to be
discharged home when sober but this am upon re-eval at 8am she
was tremulous, tachy to 105 and BP 157. She was given 10mg PO
valium and pulse went up to 110 and BP continued to incr to 167.
She felt more tremulous so got another 10 po valium. On
transfer from the ED, vitals were HR 88 BP 126/86 R 19 O2 sat
100% on RA. She was noted to still be quite shaky and
transferred to the ICU for frequent monitoring with withdrawl
given her reported h/o withdrawl seizure.
On arrival to the ICU, she c/o blurred vision, lightheadedness,
weakness, palpitations and mild nausea. She also states she
often has sweats followed by shivers at night. She states she
has chronic bronchitis with a smoker's cough. She has recently
been congested. She denies dysuria but states she has incr
frequency and urgency.
Past Medical History:
ETOH abuse- states she had the only seizure of her life [**5-26**]
when at [**Month/Year (2) **] in [**Location (un) 5503**] for rehab. Was then d/c'd on
?trileptal [**2188-6-15**]
DM type II
Chronic bronchitis
Social History:
Lives alone and is on disability.
- Tobacco: 2 packs per day
- Alcohol: drank about 1 gallon of vodka in last 10 days.
States she drinks heavily at the beginning of each month but
then runs out of money and drinks very little. Of note, was in
[**Hospital **] rehab at [**Hospital **] in [**Location (un) 5503**] until [**6-15**]. Last drink about
7p on [**2188-7-25**]
- Illicits: denies
Family History:
Non-contributory
Physical Exam:
VS: Tmax: 36.3 ??????C (97.4 ??????F), HR: 98 (86 - 100) bpm, BP: 147/98,
RR: 23 (18 - 26) insp/min, SpO2: 98%
General Appearance: Thin, Anxious, Diaphoretic, tremulous
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Poor dentition
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , Wheezes : diffusely)
Abdominal: Non-tender, Bowel sounds present, No(t) Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Normal
Pertinent Results:
Admission Labs
[**2188-7-26**] 12:50AM BLOOD WBC-7.1 RBC-3.66* Hgb-11.3* Hct-31.8*
MCV-87 MCH-30.9 MCHC-35.6* RDW-15.2 Plt Ct-289
[**2188-7-26**] 12:50AM BLOOD Neuts-62.3 Lymphs-32.5 Monos-3.5 Eos-1.1
Baso-0.7
[**2188-7-26**] 12:50AM BLOOD PT-13.1 PTT-28.2 INR(PT)-1.1
[**2188-7-26**] 12:50AM BLOOD Plt Ct-289
[**2188-7-26**] 12:50AM BLOOD Glucose-85 UreaN-15 Creat-0.4 Na-147*
K-3.3 Cl-110* HCO3-22 AnGap-18
[**2188-7-26**] 03:00PM BLOOD ALT-40 AST-48* AlkPhos-65 TotBili-0.6
[**2188-7-26**] 03:00PM BLOOD Albumin-4.1 Calcium-7.7* Phos-2.3*
Mg-1.1*
[**2188-7-26**] 11:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2188-7-26**] 11:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2188-7-26**] 11:30AM URINE RBC-0-2 WBC-[**3-21**] Bacteri-FEW Yeast-NONE
Epi-0-2
Discharge Labs
[**2188-7-28**] 06:20AM BLOOD WBC-6.8 RBC-4.29 Hgb-13.3 Hct-38.2 MCV-89
MCH-30.9 MCHC-34.7 RDW-15.4 Plt Ct-245
[**2188-7-28**] 06:20AM BLOOD Plt Ct-245
[**2188-7-28**] 06:20AM BLOOD Glucose-144* UreaN-10 Creat-0.4 Na-140
K-4.5 Cl-107 HCO3-23 AnGap-15
[**2188-7-28**] 06:20AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0
Brief Hospital Course:
Ms. [**Known lastname 80827**] is a 51 yo F w/ h/o ETOH abuse, DM2 who presented
to our ED from OSH with a depressed temporal skull fx with small
amt of pneumocephalus, and who began to withdraw from EtOH while
pt was in ED; also complaining of UTI symptoms.
.
1) ETOH abuse: Pt noted to have symptoms of withdrawal while
being observed in ED. Pt states that her last drink was on [**7-25**],
however, she has a history of ETOH withdrawl seizure at rehab in
[**2188-5-17**], so she was observed in the ICU. CIWA scale completed
q2h, with PRN diazepam 5-10mg. Pt also received folate,
thiamine, MVI. Did not administer anti-seizure medications
given unclear history of a single EtOH withdrawal seizure. The
ICU team attempted to contact [**Name (NI) **] re: h/o EtOH-WD-related SZ,
but unable to reach anyone after several tries. LFTs only with
slightly increased AST consistent with some ETOH damage, but no
cirrhosis. Pt had not recieved diazepam for 12+ hours and had
clear cognition and was not tremulous on exam prior ro d/c.
patient expressed desire to quit her drinking. Social work met
with patient and provided support and contact information for
substance abuse resources.
.
2) Skull fx with small pneumocephalus: Pt noted to have a
temporal skull fx on CT scan, but per neurosurgery, likely old
with no need for acute intervention. Pt did not report sx
associated with skull fracture. Has neurosurgery follow-up
scheduled with Dr. [**Last Name (STitle) 548**] in 2 weeks. Cephalexin prophylaxis
recommended by neurosurgery given pneumocephalus. She initially
got one dose of ceftriaxone for pssible UTI, but when urine Cx
was negative was switched to po cephalexin. pt given Rx for
cephalexin to complete a total 10 day course (day 1 = [**7-26**]).
.
3) DM: Pt's home metformin was held. It was suspected that her
diabetes wa related to alcohol-induced pancreatic damage rather
than insulin reisstance. She was placed on an insulin sliding
scale. Fasting blood sugars were less than 150s throughout
admission.
.
4) UTI: Pt reported some urinary frequency, and UA was positive
for few bacteria, trace leukocyte esterase, 3-5 WBCs. Pt got one
dose ceftriaxone, which was then d/c when urine Cx was negative.
Pt was not complaining of dysuria, and urinary frequency was
presumed to be [**2-19**] increased po fluid intake.
.
5) Nicotine Abuse: Pt started on a nicotine patch while
inpatient. Continuing smoking cessation was discussed with pt.
Pt expressed that she would like to quit EtOH first and then
subsequently actively work on smoking cessation. Pt has
substance abuse resource information that was provided by social
work.
Medications on Admission:
metformin, dose unknown
Tegretol, dose unknown
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 23 doses: Please finish all of this medication.
Disp:*23 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Alcohol withdrawl
Skull fracture
SECONDARY DIAGNOSIS
DM
Anxiety
Discharge Condition:
Mental status: clear and coherent
Hemodynamically stable
Ambulates without assistance
Discharge Instructions:
You were transferred to the [**Hospital1 18**] from an outside hospital after
experiencing bleeding from a head cut. At the outside hospital
they take pictures of your head and you were found to have a
small skull fracture. Neurosurgery saw you and deemed no
surgical intervention was recovered however they did recommend a
10 day course of antibiotics.
While in the hospital you experienced symptoms of alcohol
withdrawal: headache, fast heart rate, tremors. You were
monitored every 2hrs and received valium as needed.
You had been experiencing increased urinary frequency however a
urine test was negative for any infection.
You were discharged home when your vital signs stabilized.
The following changes were made to your medications:
START: Keflex (antibiotic) 500mg by mouth twice daily for 5 more
days with last dose being on [**2188-8-4**].
You can stop taking your metformin and tegretol until you follow
up with your PCP on Tuesday.
You can reach the substance abuse hotline at 1[**Telephone/Fax (1) 60237**].
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 12471**], the social worker who saw you, can be reached at
[**Telephone/Fax (1) 57081**].
Followup Instructions:
Please f/u with your PCP. [**Name10 (NameIs) **] that time you should readdress your
baseline anxiety and depression. You should also express your
concerns over right breast lump and need for outpatient
mammography.
Your appointment is scheduled for Tuesday [**8-5**] at 2:30.
Please also follow up with neurosurgery, Dr. [**Last Name (STitle) 548**]
When: TUESDAY [**2188-8-12**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage.
Some of the concerns that you mentioned during your stay are
that you once had a bleeding ulcer for which you were prescribed
protonix, you have a recent diagnosis of diabetes for which you
were prescribed metformin, you have a history of breast cancer
and have not had a recent mammogram, you are interested in
quitting smoking and have been on a nicotine patch, and you have
history of high cholesterol for which you were given Lipitor.
During routine testing for MRSA and you were found to be
colonized. You can take an over the counter calcium with vitamin
D supplement if you are worried you are not getting enough
calcium in your diet.
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icd9cm
|
[
[
[]
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[
"94.62"
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icd9pcs
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[
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8228, 8234
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331, 337
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3809, 4985
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9,768
| 157,881
|
53600
|
Discharge summary
|
report
|
Admission Date: [**2198-2-5**] Discharge Date: [**2198-2-8**]
Date of Birth: [**2123-10-10**] Sex: M
Service:
ADMISSION DIAGNOSIS: Aphasia.
DISCHARGE DIAGNOSIS: Malignant hypertension/Confusion.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old right
handed male who presented on the morning of [**2198-2-5**].
Around 8 a.m. he was last well, when his wife saw him next
around 9:30 in the morning, he did not answer any questions
and barely responded with a shrug of his shoulders. He did
not have any obvious weakness and was able to walk normally
in the house. His wife called emergency medical services,
who noted the patient was "staring." EMS arrived around
11:57 in the morning and found a lack of speech as well as an
inability to follow commands. When the patient was asked
about this, patient says he "can't speak like he used to."
He denies headache, visual changes, weakness, or numbness.
The wife reports he was not complaining of headache or any
visual changes. He did not have any fever or recent
illnesses at home. He denies any recent head trauma. He has
had no recent cold sores or exposure to people with cold
sores.
His initial blood pressure at presentation was greater than
systolics of 260s over diastolics of 120s. He initially
required intravenous Labetalol to decrease it. Initial chest
x-ray showed a possible retrocardiac opacity suspicious for
pneumonia. Patient was started on Levofloxacin and Flagyl.
His cardiac enzymes have been negative. His clinical exam
has rapidly improved.
On the day following admission the patient reports seeing
kids at the bedside but knows that they were not there. When
he asked his wife about this, she also says that they were
not there consistent with a possible visual hallucination.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Colon cancer status post radiation therapy and
chemotherapy with recurrence in [**2188**] with resection and a
colostomy.
4. End-stage renal disease and is on dialysis, hemodialysis
specifically.
5. Mitral regurgitation.
6. Congestive heart failure.
7. Left retinal hemorrhage in [**2196**].
8. Cholecystectomy in [**2186**] for gallstone pancreatitis.
9. Known left temporal meningioma.
10. Generalized tonic-clonic seizure six years ago after
dialysis.
He has no history of stroke, myocardial infarction, or high
cholesterol.
Further details of his admit physical and neurological exams,
please see admit notes.
ASSESSMENT AND PLAN: This is a 74-year-old male who had a
short episode of language difficulties that rapidly improved.
No clear diagnosis has been detected. His MRI and MRA were
unremarkable except for the appearance of the left temporal
meningioma. He is left handed so is not certain which side
his language center is on.
He also had a very high blood pressure when he first came in.
Perhaps he has a hypertensive encephalopathy, although he
rapidly improved and his MRI did not show any sort of
posterior leukoencephalopathy. Another possibility would be
a seizure or transient ischemic attack. This would be a
quite an unusual presentation for an acute bleed/dementia
type presentation although he does have some elements of that
on his exam.
While he remained in the hospital he did not have any further
events similar to this one. His blood pressure remained well
controlled. He was started on folate because of his elevated
homocysteine. Also started Lipitor for the patient for
stroke prophylaxis, and we continued him on his aspirin. The
Renal service saw him and suggested several changes to his
blood pressure medications, which we have done. He did have
one run of tachycardia on returning from hemodialysis. His
EKG was unchanged since admission.
We will discharge the patient to home with follow up in the
outpatient clinic. He will see Dr. [**First Name (STitle) **] as an outpatient
and will continue hemodialysis with his renal doctor, Dr.
[**First Name (STitle) 805**]. He will also see his primary care physician in his
clinic.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg a day.
2. Calcium carbonate 1000 mg p.o. t.i.d.
3. Atorvastatin 2 mg p.o. q. day.
4. Folic acid 1 mg a day.
5. Losartan 50 mg, one tablet, p.o. q. day.
6. Flagyl 500 mg p.o. q. 12 hours for seven days.
7. Levofloxacin 250 mg every other day for 14 days.
8. Minoxidil 2.5 mg p.o. b.i.d.
9. Lopressor 200 mg p.o. b.i.d.
10. Nifedipine Extended Release 120 mg p.o. q. day.
Please note the patient was also seen and evaluated by
Physical Therapy who felt that the patient was stable for
discharge to home.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Last Name (NamePattern1) 10209**]
MEDQUIST36
D: [**2198-2-8**] 15:28
T: [**2198-2-10**] 11:59
JOB#: [**Job Number 110129**]
|
[
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icd9cm
|
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[
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180, 215
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148, 158
|
244, 1785
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1807, 4031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,641
| 107,130
|
34506
|
Discharge summary
|
report
|
Admission Date: [**2171-9-8**] Discharge Date: [**2171-10-7**]
Date of Birth: [**2088-3-20**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Benadryl / Prednisone / Reglan
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
AAA,leak
Major Surgical or Invasive Procedure:
EVAR [**2171-9-8**]
right axillo femoral bpg with PTFE [**2171-9-8**]
fem-fem bpg [**2171-9-9**]
primary closeure of left faciotomy wounds, rt. faciotomy wounds
closed with split thickness skin graft. Vac dressing to rt.
wounds [**2171-9-24**]
History of Present Illness:
Ms. [**Known lastname 79272**] is an 83F with a known 6cm AAA who presented to
Caritas [**Hospital6 **] on [**9-7**] with ~36 hours of low back
pain. Of note, her blood pressure there was 180/100. A CT scan
of her abdomen was done there and confirmed a 6cm infrarenal AAA
beginning 5cm below the R renal artery and extending to the
level
of the bifurcation, surrounded by hyperdense material suggestive
of a leak. In additional, parastomal and pelvic ventral hernias
were noted without evidence of bowel obstruction.
She was transferred to [**Hospital1 18**] for further care. Upon arrival she
complained of severe low back and had a blood pressure of
220/110. She was taken directly to CT scan.
Past Medical History:
history of congestive heart failure, systolic, chronic
history of PVD
history of COPD
history of diverticulitis with abcess s/p colestomy [**2168**]
history of right hip surgery
history of rt. ankle fx
history of heavy tobacco use-current (100 pack years)
Social History:
she lives in a downstairs apartment of a two-family
house in Metheun, with her niece [**Name (NI) **] upstairs. She states
[**Known firstname **] helps with the cooking and cleaning and is generally pt's
main support. Pt also states she has had VNA at home and
describes being used to a fairly independent lifestyle with
support from niece. Also current heavy tobacco use, denies
ETOH.
Family History:
unknown
Physical Exam:
Vital signs: P-90-110 B/P 220/110
GEN: patient in distress/pain
ABD: obese colostomy LLQ, moderate tenderness to palpation
Pulses: dopperable throughout.
Pertinent Results:
[**2171-9-8**] 09:05AM BLOOD WBC-8.6 RBC-3.08* Hgb-9.4* Hct-25.5*
MCV-83 MCH-30.6 MCHC-36.9* RDW-14.9 Plt Ct-151
[**2171-9-8**] 04:36PM BLOOD WBC-10.5 RBC-2.87* Hgb-8.9* Hct-23.8*
MCV-83 MCH-30.9 MCHC-37.2* RDW-15.3 Plt Ct-140*
[**2171-9-8**] 10:18PM BLOOD WBC-16.4*# RBC-4.05*# Hgb-11.8*#
Hct-33.7*# MCV-83 MCH-29.1 MCHC-34.9 RDW-15.8* Plt Ct-158
[**2171-9-9**] 03:16AM BLOOD WBC-11.7* RBC-3.13* Hgb-9.5* Hct-26.0*
MCV-83 MCH-30.2 MCHC-36.4* RDW-15.9* Plt Ct-128*
[**2171-9-9**] 11:03AM BLOOD WBC-10.2 RBC-3.26* Hgb-9.8* Hct-26.9*
MCV-83 MCH-30.0 MCHC-36.3* RDW-15.5 Plt Ct-119*
[**2171-9-9**] 04:24PM BLOOD WBC-9.9 RBC-3.77* Hgb-11.2* Hct-31.3*
MCV-83 MCH-29.7 MCHC-35.8* RDW-15.2 Plt Ct-99*
[**2171-9-9**] 09:13PM BLOOD Hct-30.2*
[**2171-9-10**] 01:05AM BLOOD WBC-6.4 RBC-2.88* Hgb-8.5* Hct-23.6*
MCV-82 MCH-29.5 MCHC-35.9* RDW-15.6* Plt Ct-81*
[**2171-9-10**] 01:29AM BLOOD Hct-22.9*
[**2171-9-10**] 04:45AM BLOOD Hct-28.2*
[**2171-9-10**] 03:49PM BLOOD Hct-25.7*
[**2171-9-10**] 06:31PM BLOOD Hct-27.9*
[**2171-9-11**] 01:59AM BLOOD WBC-5.6 RBC-3.27* Hgb-9.8* Hct-26.9*
MCV-82 MCH-29.9 MCHC-36.3* RDW-17.1* Plt Ct-75*
[**2171-9-11**] 09:01AM BLOOD Hct-28.2*
[**2171-9-11**] 09:01AM BLOOD Hct-28.2*
[**2171-9-12**] 01:57AM BLOOD WBC-6.6 RBC-3.20* Hgb-9.5* Hct-26.5*
MCV-83 MCH-29.8 MCHC-36.0* RDW-17.1* Plt Ct-76*
[**2171-9-13**] 03:07AM BLOOD WBC-8.2 RBC-3.17* Hgb-9.4* Hct-26.4*
MCV-83 MCH-29.7 MCHC-35.6* RDW-16.7* Plt Ct-107*
[**2171-9-13**] 08:43PM BLOOD Hct-26.9*
[**2171-9-14**] 03:06AM BLOOD WBC-6.9 RBC-3.18* Hgb-9.4* Hct-27.0*
MCV-85 MCH-29.5 MCHC-34.7 RDW-15.8* Plt Ct-119*
[**2171-9-15**] 03:37AM BLOOD WBC-6.8 RBC-3.27* Hgb-9.6* Hct-27.6*
MCV-84 MCH-29.3 MCHC-34.7 RDW-16.2* Plt Ct-148*
[**2171-9-16**] 05:48AM BLOOD WBC-6.7 RBC-3.19* Hgb-9.2* Hct-27.4*
MCV-86 MCH-28.9 MCHC-33.6 RDW-16.1* Plt Ct-163
[**2171-9-17**] 04:34AM BLOOD WBC-7.5 RBC-3.15* Hgb-9.2* Hct-27.1*
MCV-86 MCH-29.1 MCHC-33.8 RDW-15.9* Plt Ct-192
[**2171-9-18**] 04:11AM BLOOD WBC-10.9 RBC-2.97* Hgb-8.9* Hct-25.7*
MCV-87 MCH-30.1 MCHC-34.8 RDW-16.0* Plt Ct-202
[**2171-9-18**] 04:03PM BLOOD Hct-23.9*
[**2171-9-19**] 05:36AM BLOOD WBC-14.3* RBC-2.98* Hgb-8.9* Hct-25.9*
MCV-87 MCH-29.8 MCHC-34.4 RDW-16.1* Plt Ct-219
[**2171-9-20**] 04:47AM BLOOD WBC-13.9* RBC-2.78* Hgb-8.3* Hct-23.6*
MCV-85 MCH-29.8 MCHC-35.0 RDW-16.6* Plt Ct-249
[**2171-9-20**] 06:41PM BLOOD Hct-25.7*
[**2171-9-21**] 04:40AM BLOOD WBC-11.3* RBC-3.12* Hgb-9.4* Hct-26.3*
MCV-84 MCH-30.1 MCHC-35.8* RDW-16.6* Plt Ct-240
[**2171-9-22**] 04:06AM BLOOD WBC-13.0* RBC-3.18* Hgb-9.4* Hct-26.7*
MCV-84 MCH-29.6 MCHC-35.2* RDW-16.6* Plt Ct-323
[**2171-9-23**] 05:35AM BLOOD WBC-9.3 RBC-2.88* Hgb-8.5* Hct-25.1*
MCV-87 MCH-29.5 MCHC-33.8 RDW-16.4* Plt Ct-324
[**2171-9-23**] 09:00PM BLOOD Hct-25.4*
[**2171-9-24**] 04:09AM BLOOD WBC-9.0 RBC-2.92* Hgb-8.3* Hct-24.8*
MCV-85 MCH-28.3 MCHC-33.3 RDW-17.1* Plt Ct-261
[**2171-9-24**] 04:05PM BLOOD Hct-22.4*
[**2171-9-25**] 04:14AM BLOOD WBC-9.6 RBC-3.31* Hgb-9.9* Hct-27.7*
MCV-84 MCH-30.0 MCHC-35.9* RDW-16.9* Plt Ct-288
[**2171-9-26**] 12:20AM BLOOD Hct-26.3*
[**2171-9-26**] 07:21AM BLOOD WBC-7.3 RBC-3.18* Hgb-9.3* Hct-26.7*
MCV-84 MCH-29.1 MCHC-34.8 RDW-17.0* Plt Ct-288
[**2171-9-27**] 04:52AM BLOOD WBC-7.2 RBC-2.93* Hgb-8.7* Hct-25.3*
MCV-87 MCH-29.6 MCHC-34.2 RDW-16.6* Plt Ct-275
[**2171-9-28**] 06:42AM BLOOD WBC-7.4 RBC-3.22* Hgb-9.3* Hct-27.8*
MCV-86 MCH-28.8 MCHC-33.4 RDW-16.6* Plt Ct-281
[**2171-9-28**] 01:10PM BLOOD WBC-8.1 RBC-3.27* Hgb-9.5* Hct-27.9*
MCV-85 MCH-29.2 MCHC-34.1 RDW-16.5* Plt Ct-286
[**2171-9-30**] 05:00AM BLOOD WBC-7.7 RBC-2.93* Hgb-8.7* Hct-25.6*
MCV-88 MCH-29.6 MCHC-33.8 RDW-16.8* Plt Ct-283
[**2171-10-1**] 05:56AM BLOOD WBC-7.0 RBC-2.84* Hgb-8.5* Hct-24.6*
MCV-86 MCH-29.7 MCHC-34.4 RDW-17.3* Plt Ct-313
[**2171-10-2**] 06:00AM BLOOD WBC-7.4 RBC-2.85* Hgb-8.5* Hct-25.0*
MCV-88 MCH-29.7 MCHC-33.9 RDW-16.8* Plt Ct-305
[**2171-10-4**] 12:00AM BLOOD WBC-7.7 RBC-3.34*# Hgb-9.8*# Hct-28.4*
MCV-85 MCH-29.5 MCHC-34.7 RDW-17.2* Plt Ct-332
[**2171-10-4**] 05:18AM BLOOD WBC-7.2 RBC-3.22* Hgb-9.7* Hct-27.4*
MCV-85 MCH-30.0 MCHC-35.3* RDW-17.2* Plt Ct-318
[**2171-10-4**] 10:27PM BLOOD Hct-28.5*
[**2171-10-5**] 05:24AM BLOOD WBC-8.0 RBC-3.37* Hgb-9.9* Hct-28.7*
MCV-85 MCH-29.4 MCHC-34.6 RDW-17.3* Plt Ct-355
[**2171-10-6**] 06:50AM BLOOD WBC-8.3 RBC-3.51* Hgb-10.5* Hct-30.5*
MCV-87 MCH-30.0 MCHC-34.4 RDW-17.0* Plt Ct-359
[**2171-9-8**] 09:05AM BLOOD ALT-5 AST-10 CK(CPK)-61 AlkPhos-49
TotBili-0.9
[**2171-9-8**] 04:36PM BLOOD ALT-8 AST-26 CK(CPK)-1049* AlkPhos-51
Amylase-27
[**2171-9-8**] 10:18PM BLOOD CK(CPK)-9379*
[**2171-9-9**] 03:16AM BLOOD ALT-25 AST-91* CK(CPK)-8909* Amylase-24
TotBili-0.6
[**2171-9-10**] 01:05AM BLOOD ALT-53* AST-214* LD(LDH)-740*
CK(CPK)-[**Numeric Identifier **]* AlkPhos-41 Amylase-20 TotBili-0.7
[**2171-9-10**] 08:09AM BLOOD CK(CPK)-[**Numeric Identifier 79273**]*
[**2171-9-10**] 09:33AM BLOOD CK(CPK)-[**Numeric Identifier 79274**]*
[**2171-9-10**] 05:25PM BLOOD CK(CPK)-[**Numeric Identifier 79275**]*
[**2171-9-10**] 10:31PM BLOOD CK(CPK)-[**Numeric Identifier 79276**]*
[**2171-9-11**] 09:01AM BLOOD CK(CPK)-[**Numeric Identifier 35232**]*
[**2171-9-13**] 03:07AM BLOOD CK(CPK)-[**Numeric Identifier 79277**]*
[**2171-9-16**] 05:48AM BLOOD CK(CPK)-5857*
[**2171-9-17**] 04:34AM BLOOD CK(CPK)-3861*
[**2171-9-18**] 04:11AM BLOOD CK(CPK)-2544*
[**2171-10-2**] 04:57PM BLOOD ALT-14 AST-24 CK(CPK)-317* AlkPhos-66
Amylase-27 TotBili-0.4
[**2171-9-8**] 09:05AM BLOOD Glucose-116* UreaN-27* Creat-1.3* Na-137
K-4.8 Cl-111* HCO3-21* AnGap-10
[**2171-9-8**] 04:36PM BLOOD Glucose-121* UreaN-28* Creat-0.9 Na-139
K-5.0 Cl-110* HCO3-21* AnGap-13
[**2171-9-9**] 03:16AM BLOOD Glucose-111* UreaN-30* Creat-1.8* Na-138
K-4.5 Cl-109* HCO3-21* AnGap-13
[**2171-9-9**] 04:24PM BLOOD Glucose-90 UreaN-29* Creat-1.9* Na-137
K-4.9 Cl-111* HCO3-19* AnGap-12
[**2171-9-9**] 09:13PM BLOOD UreaN-31* Creat-2.0* HCO3-19*
[**2171-9-10**] 01:05AM BLOOD UreaN-31* Creat-2.1* Cl-108 HCO3-21*
[**2171-9-11**] 01:59AM BLOOD Glucose-107* UreaN-32* Creat-2.7* Na-137
K-5.0 Cl-110* HCO3-18* AnGap-14
[**2171-9-13**] 03:07AM BLOOD Glucose-75 UreaN-39* Creat-3.2* Na-136
K-4.5 Cl-96 HCO3-30 AnGap-15
[**2171-9-14**] 03:06AM BLOOD Glucose-82 UreaN-43* Creat-3.4* Na-137
K-3.7 Cl-93* HCO3-33* AnGap-15
[**2171-9-15**] 03:37AM BLOOD Glucose-103 UreaN-45* Creat-3.0* Na-138
K-3.7 Cl-96 HCO3-31 AnGap-15
[**2171-9-16**] 05:48AM BLOOD Glucose-132* UreaN-51* Creat-2.8* Na-137
K-3.8 Cl-96 HCO3-34* AnGap-11
[**2171-9-17**] 04:34AM BLOOD Glucose-112* UreaN-45* Creat-2.2* Na-137
K-3.4 Cl-97 HCO3-31 AnGap-12
[**2171-9-18**] 04:11AM BLOOD Glucose-145* UreaN-42* Creat-2.1* Na-136
K-3.2* Cl-96 HCO3-29 AnGap-14
[**2171-9-19**] 05:36AM BLOOD Glucose-149* UreaN-44* Creat-1.9* Na-135
K-4.5 Cl-99 HCO3-25 AnGap-16
[**2171-9-20**] 04:47AM BLOOD UreaN-44* Creat-2.0*
[**2171-9-21**] 04:40AM BLOOD Glucose-117* UreaN-44* Creat-1.9* Na-135
K-3.6 Cl-98 HCO3-30 AnGap-11
[**2171-9-22**] 04:06AM BLOOD Glucose-97 UreaN-42* Creat-1.8* Na-134
K-3.8 Cl-96 HCO3-30 AnGap-12
[**2171-9-23**] 05:35AM BLOOD Glucose-89 UreaN-38* Creat-1.6* Na-137
K-3.9 Cl-97 HCO3-29 AnGap-15
[**2171-9-24**] 04:09AM BLOOD Glucose-90 UreaN-33* Creat-1.3* Na-137
K-4.1 Cl-101 HCO3-29 AnGap-11
[**2171-9-25**] 04:14AM BLOOD Glucose-103 UreaN-32* Creat-1.3* Na-136
K-3.9 Cl-100 HCO3-28 AnGap-12
[**2171-9-26**] 07:21AM BLOOD Glucose-99 UreaN-29* Creat-1.2* Na-137
K-3.8 Cl-101 HCO3-28 AnGap-12
[**2171-9-27**] 04:52AM BLOOD Glucose-105 UreaN-28* Creat-1.2* Na-138
K-3.7 Cl-102 HCO3-29 AnGap-11
[**2171-9-28**] 06:42AM BLOOD Glucose-103 UreaN-27* Creat-1.2* Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
[**2171-9-30**] 05:00AM BLOOD Glucose-87 UreaN-32* Creat-1.2* Na-136
K-4.3 Cl-101 HCO3-29 AnGap-10
[**2171-10-1**] 05:56AM BLOOD Glucose-95 UreaN-35* Creat-1.3* Na-138
K-4.2 Cl-103 HCO3-27 AnGap-12
[**2171-10-2**] 06:00AM BLOOD Glucose-99 UreaN-36* Creat-1.4* Na-134
K-4.4 Cl-103 HCO3-27 AnGap-8
[**2171-10-4**] 05:18AM BLOOD Glucose-93 UreaN-39* Creat-1.3* Na-138
K-4.4 Cl-103 HCO3-27 AnGap-12
[**2171-10-4**] 10:27PM BLOOD Creat-1.2* K-4.6
[**2171-10-6**] 06:50AM BLOOD Creat-1.3* K-4.9
[**2171-10-7**] 02:09AM BLOOD Glucose-92 UreaN-44* Creat-1.3* Na-135
K-4.1 Cl-102 HCO3-26 AnGap-11
[**2171-10-2**] 04:57PM BLOOD ESR-79*
[**2171-9-8**] 04:36PM BLOOD PT-14.0* PTT-76.1* INR(PT)-1.2*
[**2171-9-9**] 04:24PM BLOOD PT-14.0* PTT-56.3* INR(PT)-1.2*
[**2171-9-10**] 01:05AM BLOOD PT-14.5* PTT-80.7* INR(PT)-1.3*
[**2171-9-10**] 05:50AM BLOOD PT-13.8* PTT-47.4* INR(PT)-1.2*
[**2171-9-10**] 03:49PM BLOOD PT-13.0 PTT-38.3* INR(PT)-1.1
[**2171-9-12**] 01:57AM BLOOD PT-12.8 PTT-39.5* INR(PT)-1.1
[**2171-9-14**] 03:06AM BLOOD PT-12.5 PTT-55.3* INR(PT)-1.1
[**2171-9-15**] 03:37AM BLOOD PT-12.6 PTT-57.8* INR(PT)-1.1
[**2171-9-16**] 05:48AM BLOOD PT-12.6 PTT-64.6* INR(PT)-1.1
[**2171-9-16**] 03:00PM BLOOD PTT-61.2*
[**2171-9-18**] 04:11AM BLOOD PT-13.4 PTT-58.3* INR(PT)-1.2*
[**2171-9-19**] 05:36AM BLOOD PT-17.2* PTT-71.1* INR(PT)-1.6*
[**2171-9-21**] 07:15PM BLOOD PT-18.3* PTT-57.3* INR(PT)-1.7*
[**2171-9-22**] 04:06AM BLOOD PT-15.9* PTT-50.1* INR(PT)-1.4*
[**2171-9-23**] 09:00PM BLOOD PT-14.1* PTT-54.8* INR(PT)-1.2*
[**2171-9-24**] 04:09AM BLOOD PT-14.3* PTT-66.7* INR(PT)-1.2*
[**2171-9-25**] 04:14AM BLOOD PT-14.6* PTT-67.2* INR(PT)-1.3*
[**2171-9-25**] 09:59AM BLOOD PT-15.4* PTT-75.1* INR(PT)-1.4*
[**2171-9-26**] 12:20AM BLOOD PT-16.8* PTT-75.5* INR(PT)-1.5*
[**2171-9-26**] 07:21AM BLOOD PT-17.5* PTT-77.9* INR(PT)-1.6*
[**2171-9-30**] 05:00AM BLOOD PT-20.0* PTT-34.2 INR(PT)-1.9*
[**2171-10-1**] 05:56AM BLOOD PT-25.4* PTT-37.5* INR(PT)-2.5*
[**2171-10-2**] 06:00AM BLOOD PT-30.1* PTT-39.8* INR(PT)-3.1*
[**2171-10-3**] 05:26AM BLOOD PT-28.3* PTT-47.1* INR(PT)-2.8*
[**2171-10-4**] 05:18AM BLOOD PT-25.7* PTT-63.4* INR(PT)-2.5*
[**2171-10-4**] 10:27PM BLOOD PT-30.3* INR(PT)-3.1*
[**2171-10-5**] 05:24AM BLOOD PT-31.4* PTT-43.0* INR(PT)-3.2*
[**2171-10-5**] 05:24AM BLOOD PT-31.4* PTT-43.0* INR(PT)-3.2*
[**2171-10-6**] 06:50AM BLOOD PT-31.6* PTT-44.4* INR(PT)-3.3*
[**2171-10-7**] 02:09AM BLOOD PT-32.0* PTT-59.0* INR(PT)-3.3*
[**2171-9-8**] 09:05AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2171-9-8**] 04:36PM BLOOD CK-MB-8 cTropnT-0.02*
[**2171-9-8**] 10:18PM BLOOD CK-MB-37* MB Indx-0.4 cTropnT-0.03*
[**2171-9-9**] 03:16AM BLOOD CK-MB-33* MB Indx-0.4 cTropnT-0.03*
[**2171-9-10**] 08:09AM BLOOD CK-MB-80* MB Indx-0.3 cTropnT-0.09*
[**2171-9-10**] 09:33AM BLOOD cTropnT-0.10*
[**2171-9-10**] 05:25PM BLOOD cTropnT-0.20*
[**2171-9-10**] 10:31PM BLOOD CK-MB-72* MB Indx-0.3 cTropnT-0.25*
[**2171-10-2**] 04:57PM BLOOD TSH-12*
[**2171-9-8**] 04:54AM BLOOD Type-ART pO2-340* pCO2-44 pH-7.36
calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2171-9-8**] 06:27AM BLOOD Type-ART pO2-273* pCO2-46* pH-7.33*
calTCO2-25 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2171-9-8**] 12:49PM BLOOD Type-ART pO2-116* pCO2-44 pH-7.35
calTCO2-25 Base XS--1
[**2171-9-10**] 08:57PM BLOOD Type-ART pO2-82* pCO2-34* pH-7.32*
calTCO2-18* Base XS--7
[**2171-9-12**] 02:09AM BLOOD Type-ART pO2-89 pCO2-41 pH-7.42
calTCO2-28 Base XS-1
[**2171-9-14**] 05:32AM BLOOD Type-ART pO2-64* pCO2-54* pH-7.41
calTCO2-35* Base XS-7
[**2171-9-15**] 02:26PM BLOOD Type-ART pO2-97 pCO2-55* pH-7.41
calTCO2-36* Base XS-7
[**2171-9-8**] 09:05AM BLOOD ALT-5 AST-10 CK(CPK)-61 AlkPhos-49
TotBili-0.9
[**2171-9-8**] 04:36PM BLOOD ALT-8 AST-26 CK(CPK)-1049* AlkPhos-51
Amylase-27
[**2171-9-8**] 10:18PM BLOOD CK(CPK)-9379*
[**2171-9-10**] 01:05AM BLOOD ALT-53* AST-214* LD(LDH)-740*
CK(CPK)-[**Numeric Identifier **]* AlkPhos-41 Amylase-20 TotBili-0.7
[**2171-9-10**] 08:09AM BLOOD CK(CPK)-[**Numeric Identifier 79273**]*
[**2171-9-13**] 03:07AM BLOOD CK(CPK)-[**Numeric Identifier 79277**]*
[**2171-9-18**] 04:11AM BLOOD CK(CPK)-2544*
[**2171-10-2**] 04:57PM BLOOD ALT-14 AST-24 CK(CPK)-317* AlkPhos-66
Amylase-27 TotBili-0.4
GRAM STAIN (Final [**2171-9-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2171-9-29**]):
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
AZTREONAM REQUESTED BY DR.[**Last Name (STitle) **].
AZTREONAM SENSITIVE BY [**Doctor Last Name **]-[**Doctor Last Name **].
ANAEROBIC CULTURE (Final [**2171-9-29**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
RAPID PLASMA REAGIN TEST (Final [**2171-10-3**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**2171-9-10**] 09:33AM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-0.2 pH-5.5 Leuks-NEG
[**2171-9-10**] 09:33AM URINE RBC-0-2 WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-0
[**2171-9-10**] 09:33AM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2171-9-8**] CT ABD PELVIS: Large, ruptured, 6 x 6 cm infrarenal
abdominal aortic aneurysm with extensive intramural thrombus and
retroperitoneal hematoma.
Severe atherosclerotic disease of the abdominal aorta and its
branches,
including near-occlusion of the right common iliac artery.
[**2171-9-9**] CXR: Indwelling devices are in standard position, and
cardiomediastinal contours
are not substantially changed allowing for technical differences
between the
studies. Worsening opacity in lower left hemithorax is likely a
combination
of pleural effusion and atelectasis. No pneumothorax is evident
on this
supine view.
[**2171-9-22**] ECG: Sinus rhythm. Prolonged Q-T interval. No previous
tracing available for comparison.
[**2171-10-4**] CT ABD/PELVIS: 1. Bilateral superficial proxmal
thigh/inguinal fluid collections, appearance
c/w hematomas. 2. Open soft tissue wound on the left groin area
with communication to the left groin fluid collection and one of
the two femoro-femoral PTFE grafts. 3. Uncomplicated ventral
hernia. 4. Mild interval decrease of aortic aneurysmal sac
diameter.
Brief Hospital Course:
[**2171-9-8**] Evaluated in ER
8/31/0 EVAR with fem-fem bpg, transfused for blood loss anemia,
acute [**Numeric Identifier 79278**] loss of rt. foot pulse with progressive ischemic
changes. Returned to [**Location 79279**].Right axillo-femoral bpg. dopperable
DP/PT with good capillary refill. dopperableleft DP absent left
PT. Transfered to SICU intubated.
[**2171-9-9**] POD#1 Remains intubated on IV ngt. gtt for SBP controll.
NTG in place. low urinary out put volume resustated. Troponin
0.03 IV insulin gtt.,propofol 40mcg/kg/min. fentyl 75mcg /hr
gtt. Vanco/cipro antibiotic coverage.
Left lower extremity ischemia Returns to OR for redo fem-fem
bpg.and bilateral fasciotomies.Transfused
[**2171-9-10**] POD#2 Transfused remain in ICU. increasing creatinine
Renal consulted.
Renal faillure secondary to ATN and rhabolomyosis and contrast
during inital endovascular repair.Recommend fluid resustation no
hemodialysis at this time.
[**2171-9-11**] POD#3 increase urinary out put with fluid resustation
and IV lasix.Nutritional consult.recommend tube feeds.IV heparin
.Sedation weaning began.
[**Hospital1 **] carb gtt for urine alklization. propfolol off. Ck's trending
down [**Hospital1 **].
[**2171-9-12**] POD#4 antibiotics and IV heparin continued. creatinine
@ 3.0
[**2171-9-13**] POD#5 [**Hospital1 **] carb gtt d/c'd. diuresis continues. continues
with tube feed. await swallow evaluation.fentyl gtt d/c'd. Iv
heparin continued. lasix continued but frequency
decreased.Antibiotics continued. Remains intubated and in ICU.
Swallow evaluation at bed side negative for aspiration.
recommended po diet of thin liquids and soft solids.Extubated.
[**2171-9-14**] POD#6 cr. 3.4 IV heparin continued. diuresuis cibtinued
for 20kg above preop wt.creatinine plateaued.
[**2171-9-15**] POD#7 cr. 3.0 today. VAC dressings to faciotomy sites.
[**2171-9-16**] POD#8 Transfered to VICU. tube feed at goal. 40cc/hr. Iv
heparin continued.
wound care consulted for left gluteal decubti.
[**2171-9-17**] POD#9 wound care suggestions instuted. creatinine
trending downward, 2.2
Pt continues to work with patient.Tube feed cycling began. Po's
continue and calorie counts monitered.
[**2171-9-18**] POD# 10 right leg wound vac changed secondary to wound
bleeding.repeat spontanious bleed , hemostasis obtained and
wound vac discontinued.
patient transfused for a Hct. 23.0
[**2171-9-19**] POD#11 post transfusion Hct. 25.1 wounds without
bleeding.
[**2171-9-20**] POD# 12 left wound vac discontinued and zeroform form
dressings and dry steral dressing with ace wraps instuted.
Patient had an episode of rt. facitoomy site bleeding requiring
surgi-sel for hemostatis.
[**2078-9-19**] POD# 13-15 continued antibiotics. patient self D/c'd her
feeding tube. which will required to be replaced secondary to
poor caloric intake by calorie counts.
patient proceeded to surgery [**2171-9-23**]
[**2171-9-23**]- [**2171-5-25**] POD#15-17 right faciotomy closure with STSG and
VAC dressing,left faciotomy closure primary.Seen by skin care
team. for colostomy site care and left decubitus cheel skin
changes.Coumadization began . IV heparin gtt continued.
Multipodis boots placed for heel protection. Left groin wound
noted to be open and exudative.
[**2171-9-26**] [**Month/Day/Year 197**]-heparin bridge continued. Monitering
graft donor site. Calorie counts ordered to assess adequacy of
PO intake
[**2171-9-27**] PO intake improved with encouragement. Wound vac
removed from graft site & dry dressing placed.
[**2171-9-30**]: Transfered to the floor. L groin wound debrided at
bedside.
[**2171-10-2**]: Sacral ulcer sharply debrided at bedside, moist to
dry dressing changes begun. Woundvac placed by team to left
groin, all surgical staples removed.
[**2171-10-4**] Pt received 2U PRBC for a falling HCT. Woundvac
changed by wound care nurse. [**First Name (Titles) 197**] [**Last Name (Titles) **] changed to
alternating 3mg/5mg doses for supratherapeutic INR on 5mg daily.
[**2171-10-7**] Pt is being discharged to [**Hospital3 **] in stable
condition with ostomy, woundvac, central line in place. Of note
is a post-op L paraplegia likely secondary to ischemia during
aortic cross-clamping, neurology consult did not reveal a
reversible cause.
Medications on Admission:
lasix & potassium
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital3 **]: Six (6)
Puff Inhalation Q6H (every 6 hours).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
6. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
7. Nicotine 14 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. [**Hospital1 197**] 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO every other day.
9. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day): to groin and peri-rectal area .
10. [**Hospital1 197**] 1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO every other
day.
11. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1 [**1-9**] Tablet PO TID (3
times a day).
13. Amlodipine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) NEB Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
15. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed.
16. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID
(2 times a day).
18. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
19. Alprazolam 0.25 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO QHS (once a
day (at bedtime)) as needed for insomia or anxiety.
20. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
21. Aztreonam 1 gram Recon Soln [**Month/Day (2) **]: One (1) gram Injection Q8H
(every 8 hours) for 4 days: Total 14 day course. Wound care
assessment to consider extending antibiotic past day 14.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
abdominal aortic aneurysem
postoperative right lower extremity acute ischemia
postoperative left foot ischemia
postoperative acute blood loss anemia, transfused, corrected
postoperative acute renal failure [**2-9**] hypovolemia,hypotension
and rhabolmyosis
postoperative failure to thrive- Tf started
postoperative left gluteal decubitus.
postoperative rt. faciaotomy wound bleed, hemostasis obtained
Discharge Condition:
Stable
Discharge Instructions:
moniter INR for goal 2.0-3.0
INR@ d/c: 3.3
Wound Care:
Site: L LE
Type: Surgical
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: [**Hospital1 **]
Site: L groin
Type: Surgical
Change dressing: every 2-3 days
Comment: Wound Vac at 75mmHg, black foam
Site: R groin
Type: Surgical
Change dressing: [**Hospital1 **]
Comment: Clean with sterile saline and cover with dry gauze in
fold to keep area dry
Site: R calf
Type: Surgical
Change Dressing: [**Hospital1 **]
Comment: cover with dry gauze and monitor for signs of
infection or necrosis of the graft
Site: R thigh
Type: Surgical--Skin Graft Donor Site
Cleansing [**Doctor Last Name 360**]: Saline
Comment: Open to air, may cover with dry gauze
Site: Sacrum
Type: Bedsore / Pressure Wound
Cleansing [**Doctor Last Name 360**]: Saline
Comment: moist to dry dressing changes daily. Monitor for
signs of infection.
Continue ostomy care
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
2-3 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**]
Completed by:[**2171-10-7**]
|
[
"440.8",
"344.1",
"496",
"441.02",
"707.05",
"428.0",
"553.20",
"728.88",
"285.1",
"276.52",
"998.11",
"440.20",
"428.22",
"569.69",
"707.07",
"584.5",
"568.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.28",
"88.42",
"83.14",
"99.04",
"39.71",
"39.29",
"86.22",
"96.6",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
22880, 22923
|
16012, 20250
|
312, 558
|
23368, 23377
|
2189, 15989
|
26037, 26166
|
1990, 1999
|
20318, 22857
|
22944, 23347
|
20276, 20295
|
23401, 23445
|
24375, 26014
|
2014, 2170
|
264, 274
|
23458, 24359
|
586, 1289
|
1311, 1568
|
1584, 1974
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,124
| 122,850
|
37387
|
Discharge summary
|
report
|
Admission Date: [**2179-11-15**] Discharge Date: [**2179-11-23**]
Date of Birth: [**2121-11-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Keflex / Levaquin / Actonel
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Bronchoscopy x2
History of Present Illness:
Briefly 57 yo F w/ COPD on home O2 and prednisone and
tracheobronchial malacia p/w inability to wean vent. Initially
presented to [**Hospital 1562**] hospital with SOB on [**11-4**] and was
intubated on [**11-5**] for COPD exacerbation/PNA got 11 day course
of zosyn and diflucan. She was trached on [**11-9**]. She was
bronched and diagnosed with tracheobronchial malacia at OSH and
transferred to [**Hospital1 18**] on the TSICU service. TSICU team had been
trying to wean her off of propofol but she repeatedly became
very anxious and dropped her O2 sats. She was started on
quetiapine and her propofol was stopped this am. She has failed
trials with PM valve several times. TSICU team has been
attempting to diurese her but she has continued to run positive.
Her Aline was replaced yesterday. She has been getting nutren
TFs. She is transferred to the MICU for further weaning of her
PEEP and possible stenting of her tracheobronchial malacia.
.
.
Currently, she complains of pain in the back left of her mouth.
.
ROS unobtainable [**1-18**] trach.
Past Medical History:
-Advanced COPD, on supplemental O2 (6-7L) and prednisone, last
PFTs in [**2168**], last hospitalization in [**2178-4-16**]
-Asthma
-HTN
-Hyperlipidemia
-Obesity
-Anemia
-Osteoporosis
Social History:
hx of tobacco but quit [**2163**], denies ETOH
Family History:
NC
Physical Exam:
Vitals - BP: 145/69 HR: 70 RR: 16 02 sat: 97
GENERAL: A/oX3, unable to speak [**1-18**] trach, answering yes/no
appropriately
HEENT: Trach, unable to assess JVD [**1-18**] habitus. Oral thrush
CARDIAC: RRR, Distant heart sounds
LUNG: Distant lung sounds
ABDOMEN: Massively obese, soft, NT
EXT: trace pitting edema bilaterally, 2+ DP/PT pulses
Pertinent Results:
[**2179-11-15**] 11:06PM BLOOD WBC-14.0* RBC-3.70* Hgb-10.5* Hct-34.0*
MCV-92 MCH-28.3 MCHC-30.8* RDW-15.4 Plt Ct-533*
[**2179-11-22**] 04:00AM BLOOD WBC-7.8 RBC-3.66* Hgb-10.7* Hct-33.9*
MCV-93 MCH-29.2 MCHC-31.5 RDW-15.5 Plt Ct-327
[**2179-11-22**] 04:00AM BLOOD PT-12.4 PTT-21.7* INR(PT)-1.0
[**2179-11-22**] 04:00AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-145
K-4.2 Cl-98 HCO3-40* AnGap-11
[**2179-11-15**] 11:06PM BLOOD Glucose-104 UreaN-15 Creat-0.7 Na-146*
K-3.9 Cl-104 HCO3-34* AnGap-12
[**2179-11-22**] 04:00AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.1
[**2179-11-20**] 10:32AM BLOOD Type-ART Temp-37.1 Rates-/25 PEEP-5
FiO2-40 pO2-77* pCO2-65* pH-7.36 calTCO2-38* Base XS-7
Intubat-INTUBATED Vent-SPONTANEOU
[**2179-11-19**] 04:53AM BLOOD Type-ART pO2-91 pCO2-67* pH-7.37
calTCO2-40* Base XS-9
[**2179-11-20**] 10:32AM BLOOD Lactate-0.7
CXR [**11-18**]:
Tracheostomy tube is in standard position. NG tube tip is out of
view below the diaphragm. Cardiac size is normal. The lungs are
hyperinflated Small right pleural effusion is unchanged from
prior. Of note the left lateral CP angle was not included on the
film. Minimal atelectasis is noted in the left lower lobe. There
is no pneumothorax.
Bronchoscopy [**11-22**]:
Proximal: mild tracheomalacia
Mid: moderate tracheomalacia
Distal: severe tracheomalacia
Airways: Severe right mainstem, bronchus intermedius, left
main-stem bromchomalacia.
Plan: Discharge to rehab, f/u in a few months when recovered.
Brief Hospital Course:
ASSESSMENT & PLAN: 57 yo F w/ COPD, morbid obesity, TBM and
failure to wean vent.
# Failure to wean/COPD/TBM: Appears chronic retainer. A large
component of her difficulty with weening was anxiety related.
Upon arrival at the MICU, she was gently diuresed and her
anxiety was controlled with PRN ativan. She was able to be
weened to PS 14/10 and she is able to tolerate PS 8/5 for a
short time, enough to try a Passy Muir valve for some time.
However, she feels much more comfortable with a PEEP of 10. She
does have some significant respiratory muscle weakness with a
NIF of 23, likely due to her extended ventilator exposure, with
no signs of peripheral muscle weakness. However, other
etiologies for respiratory muscle weakness should be considered
if she continues to have difficulty weening. After her PEEP was
weened down to 5 for some time, she was rebronched by the
Interventional Pulmonary service who did see some distal
tracheobronchial malacia but nothing proximal that they felt
placing a stent in would assist in her weening. She may follow
up with the IP service in several months after she has been
weened for further evaluation and treatment. She is continued on
her home dose of prednisone, combivent inhalers, and PO lasix.
Due to her ventilated status, she could not receive her home
Spriva or Foradil but these should be restarted after weening.
#Anxiety: Well controlled with Low dose PRN ativan.
.
#DMII: Blood sugars were noted to be elevated, likely
representing underlying type 2 diabetes worsened by steroids and
stress. Well controlled with an insulin sliding scale in
hospital but should be switched to PO agents at a later time
before returning home.
.
#Trach pain: Uncomfortable at the site of her tracheostomy. Well
controlled with small doses of PO dilaudid and tylenol, with
chloraseptic PRN.
#HTN: Well controlled on valsartan and diltiazem.
.
# PPX: famotidine, heparin SQ, bowel regimen
# ACCESS: PICC
# CODE: Full
# CONTACT: [**Name (NI) 4906**] [**Name (NI) **] [**Telephone/Fax (1) 84055**] (cell) [**Telephone/Fax (1) 84056**]
(home); Son [**Name (NI) **] [**Telephone/Fax (1) 84057**] (cell)
Medications on Admission:
-Prednisone 5mg qday
-Diovan 80 mg qday
-Spiriva 18mcg inh qday
-[**Doctor First Name **] 180mg qday
-Singulair 10mg qday
-Lipitor 10mg qday
-Lasix 20mg qday
-Boniva qmonth
-Foradil 12mcg inh [**Hospital1 **]
-Combivent 2puffs QID PRN
-Calcium carbonate/Vit D1 qday
-ASA 81 qday
-Albuterol 2.5mg neb q4 PRN
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: Please see
attached scale Injection ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day). mL
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for anxiety/pain.
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**4-21**]
Puffs Inhalation Q4H (every 4 hours).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day) as needed for thrush.
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
11. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for sore throat.
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
18. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
20. Diltia XT 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
21. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
Community Acquired Pneumonia
COPD exacerbation
Hypertension
Type 2 Diabetes
Discharge Condition:
Non-ambulatory, on PS [**2180-11-28**], comfortable on vent and
communicative. All vital signs stable. Alert and oriented x 3
Discharge Instructions:
You were admitted after a pneumonia and a COPD exacerbation to
continue weening you off the ventilator and evaluate whether
your airways showed any signs of collapse, known as
tracheobronchomalacia, that could be helped by a stent placed to
keep them open. The Interventional Pulmonary service evaluated
you and found that while you did have some collapse of your
small airways, there was no major collapse of the large airways
that would be helped with a stent.
Followup Instructions:
Provider: [**Name10 (NameIs) 12554**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2180-2-15**] 10:00
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2180-2-15**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2180-2-15**]
11:00
Please follow up with PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 84058**],
after discharge from rehab.
Completed by:[**2179-11-26**]
|
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"491.21",
"276.0",
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"33.21",
"96.72",
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icd9pcs
|
[
[
[]
]
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8038, 8105
|
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|
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|
8225, 8353
|
2106, 3569
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8126, 8204
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5761, 6070
|
8377, 8841
|
1736, 2087
|
286, 291
|
374, 1430
|
1452, 1637
|
1653, 1701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
518
| 107,636
|
44019
|
Discharge summary
|
report
|
Admission Date: [**2109-7-17**] Discharge Date: [**2109-7-22**]
Date of Birth: [**2062-9-18**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
SOB, increasing pedal edema
Major Surgical or Invasive Procedure:
Intubation, with successful extubation.
History of Present Illness:
[**Known firstname 94522**] [**Known lastname 94523**] is a 46-year-old gentleman with h/o DMI, ESRD on HD,
HIV (VL <50, CD4 393 [**2-13**]), recently diagnosed PE, and multiple
ED admissions for HTN urgency who presented to the ED with
complaints of SOB and LE that had progressed throughout the
evening. Sicne 11PM night PTA, dyspnea increased and patient
sought eval in ED. In [**Last Name (LF) **], [**First Name3 (LF) **] report, patient was 89% RA, and
100% on a 4L NC, appeared comfortable. EKG showed mildly peaked
Ts, and he was treated with calcium, bicarb, and D50/insulin.
Approximately 1/2 hour later, patient became acutely dyspneic
and tachypneic. Repeat EKG showed anterolateral ST segment
elevations. SBP was in 240s at that time. EKG was reviewed with
cardiology attending and cath lab was activated. Patient was
started on Bipap, nitro gtt, nipride gtt, and given lasix 100mg
IV. Breathing status looked poor, he was intubated using
Rocuronium for paralysis given ESRD. He was given heparin and
integrillin boluses for presumed ACS. Repeact CXR showed acute
pulmonary edema. Repeat EKG showed that ST segment elevations
had resolved with BP control. Bedside ECHO was done by
cardiology fellow and no wall motion abnormalities were noted.
Cath was deferred, and patient was admitted to MICU for further
management.
Past Medical History:
- Type 1 diabetes
- HIV (boosted atazanavir, lamivudine, stavudine), dx'd [**2096**]
VL <50, CD4 393 [**2-13**])
- ESRD previously on HD, attempted on PD
on transplant list (clinical study for HIV/solid organ
transplant)
- Malignant Hypertension
- hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem
- Hx schistosomiasis
- Restless leg syndrome
- Peripheral neuropathy on gabapentin
- S/p cholecystectomy
- s/p R nephrectomy in [**2092**] secondary renal nephrolithiasis
Social History:
Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**].
Works in support services for a law firm. Denies any alcohol or
IV drug use. Quit smoking last year; previous 30 pack-year
history.
Family History:
Non-contributory
Physical Exam:
T: 98.7; HR 64; BP 120/75; RR 24; O2 Sat 100%
GEN: alert and oriented, ambulating freely
HEENT: NCAT. MMM. OP clear.
NECK: Supple, No LAD.
CV: S1S2 RRR. Grade II/VI systolic murmur
LUNGS: CTAB
ABD: NABS. Soft, NT, ND.
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
ECHO [**6-15**]: [**6-/2109**] shows The left atrium is mildly dilated. The
estimated right atrial pressure is 11-15mmHg. There is mild
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF 60%). There is severe mitral
annular
calcification.
.
[**2109-7-17**] CXR
IMPRESSION: New air space process in both mid-lungs, most
suggestive of early pulmonary edema.
.
[**2109-7-17**] 06:05AM TYPE-ART TEMP-35.2 O2-100 PO2-188* PCO2-60*
PH-7.30* TOTAL CO2-31* BASE XS-2 AADO2-479 REQ O2-80
INTUBATED-INTUBATED
.
[**2109-7-17**] 05:49AM GLUCOSE-98 UREA N-52* CREAT-8.8* SODIUM-136
POTASSIUM-7.3* CHLORIDE-94* TOTAL CO2-25 ANION GAP-24*
.
[**2109-7-17**] 05:49AM CALCIUM-9.9 PHOSPHATE-11.6*# MAGNESIUM-3.5*
.
[**2109-7-17**] 05:49AM WBC-12.6*# RBC-3.40* HGB-12.7* HCT-36.7*
MCV-108* MCH-37.3* MCHC-34.6 RDW-16.4* NEUTS-84.8* LYMPHS-8.5*
MONOS-4.9 EOS-1.7 BASOS-0.1
.
[**2109-7-17**] 02:05AM CK(CPK)-89
[**2109-7-17**] 02:05AM cTropnT-0.26*
[**2109-7-17**] 02:05AM CK-MB-NotDone proBNP-[**Numeric Identifier **]*
Brief Hospital Course:
46M HIV, ESRD on HD p/w shortness of breath, intubated for
respiratory distress.
.
# RESPIRATORY DISTRESS Initially presented in an event that
appears that most recent event is secondary to acute pulmonary
edema. CXR with new pulmonary edema that developed over 1 hour.
Was emergently intubated and given nitroglycerin gtt.
Siginficantly improved with dialysis but had focal infiltrate on
post-dialysis cxr thought due to pneumonia (as well as fever).
Thus was initially started on vanc/meropenem that was changed to
just vancomycin qhd once sputum culture showed GPCs. Was
extubated without event on [**2109-7-19**] and continued to saturate
well, ultimately sating 97% on RA. Was continued on vancomycin
for presumed CAP, was discharge on day 5 of 7 with continued
dosing per HD. Volume status was continually monitored by I/Os
and daily weights. He had HD on the day of discharge and
tolerated it well. He will continue with his MWF HD where they
will monitor both his fluid status and vancomycin dosing.
.
# Benign Hypertension No history of CAD, ruled out for ACS upon
admit. Transitory EKG changes with admit hypertension, resolved
with BP control. On multiple meds [**Date Range 3782**] with recurrent admits
for HTN urgency. Simplified medications while inpatient. Upon
discharge his morning antiHTN meds included Nifedipine CR 30mg,
lisinpril 30mg, metoprolol XL 12.5mg. These differed
significantly from his admit medications. During his stay, his
atenolol and valsartan were discontinued. Nifedipine was
changed from 90 mg to CR 30 mg and Lisinopril was increased from
20 mg to 30 mg. Metoprolol 12.5 mg daily was added for
additional cardio-protection. We also changed his clonidine to a
patch instead of taking po clonidine. He was instructed to
follow-up with both his PCP and renal physicians to adjust these
medications as needed.
.
# ESRD on HD. Appreciate renal input. Urgent HD x 3 last week,
with total volume decrease of 9kg. This aided greatly in the
resolution of his pulmonary edema. He will resume his normal
MWF HD this week. His [**Date Range 766**] dialysis was peformed while
inpatient without incident. Discharged on Cinacalcet and
Lanthanum per Renal recommendations.
.
# HIV/AIDS (VL <50, CD4 393 [**2-13**]) Was maintained on his [**Month/Year (2) 3782**]
HAART medication without interuptions while inpatient. Was
discharged without altering these medications.
.
# H/O Pulmonary Embolus Diagnosed [**6-24**] and with a newly
discovered clot on [**7-7**]. Supratherapeutic in ICU, for which
coumadin was briefly held. Upon admission to the floor, was
restarted on warfarin 4mg po daily. INR was monitored and was
therapeutic on discharge. Will be followed in HD for continued
monitoring and adjustments as need.
.
# DM Type II Controlled - Last HbA1c [**2109-2-12**] 5.7. Checked
with QAC and QHS finger sticks while inpatient. The patient
actually did not receive any insulin for 5 days, and did not get
any signs or sx of DKA. He reports at home that his AM FS is
80-90 and then post-prandial goes up to 100-115, after which he
then takes his NPH. States he takes both long-acting insulin
and short-acting with meals. Given this, we strongly believe his
initial diagnosis of Type 1 DM was incorrect and in fact was a
very poorly controlled type 2. Upon discharge it was recommended
that he not take insulin unless his finger sticks were elevated
>200. At that point, if his FS >200, he was instructed to call
his primary care doctor to seek advice for continued insulin
management. Given this change, we established follow-up for Mr.
[**Known lastname 94523**] with the [**Hospital **] Clinic for [**7-26**] at 3 pm where this
will be addressed. At the recommendation of the [**Name8 (MD) **] NP, we
also drew C-PEPTIDE and INSULIN ANTIBODIES which were pending at
time of discharge and will be followed up at [**Last Name (un) **].
FULL CODE
Medications on Admission:
1. Warfarin 2 mg Tablet Sig: Three (3) Tablets PO HS (at
bedtime).
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day). Capsule(s)
3. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID (3 times a day).
4. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID
8. Prochlorperazine 20mg PRN nausea
9. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QSAT (every Saturday).
10. Ritonavir 100 mg PO qd
11. Atazanavir 300mg PO qd
12. Stavudine 20 mg PO qd
13. Lamivudine 25 PO qd
14. Metoclopramide 10 mg IV Q6H
15. Albuterol Sulfate 0.083 % q6h
16. Clonidine 0.2 mg PO BID
17. Nifedipine 90 mg PO qd
Discharge Medications:
1. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID (3 times a day).
2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Ritonavir 80 mg/mL Solution Sig: 1.25 mL PO DAILY (Daily).
5. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
7. Lamivudine 10 mg/mL Solution Sig: 2.5 mL PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*4 Patch Weekly(s)* Refills:*2*
10. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
12. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous HD PROTOCOL (HD Protochol).
15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
inhalation Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
16. Prochlorperazine 10 mg Tablet Sig: 1-2 Tablets PO twice a
day as needed for nausea.
17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypertensive crisis, acute respiratory failure
secondary to pulmonary edema, pneumonia
Secondary: ESRD requiring hemodialysis, HTN, HIV, DM, history of
PE on coumadin therapy
Discharge Condition:
Good. Hemodynamically stable and afebrile.
Discharge Instructions:
Please take all medications as directed. There have been several
changes to your medications. First, you have not required
insulin during this hospitalization. We reccomend that you do
not take insulin unless you notice that your finger sticks are
elevated >200. If your sugar is >200, call your primary care
doctor and he will advise you what to do with your insulin. We
have set you up with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes [**Last Name (NamePattern4) 648**] for [**7-26**] at 3 pm where this will be addressed. We also changed your
blood pressure medications. You should stop taking your atenolol
and valsartan. We decreased your nifedipine from 90 mg to 30 mg
and increased your lisinopril from 20 mg to 30 mg. We also added
metoprolol 12.5 mg daily. We also changed clonidine to a patch
which you should change every Friday instead of taking clonidine
by mouth. Your coumadin was decreased from 6 mg daily to 4 mg
daily.
Please follow-up with all outpatient appointments.
Take daily weights, return to ED or your PCP if you should
notice increasing shortness of breath or lower extremity
swelling.
Followup Instructions:
You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4026**] after discharge.
Please call the office at [**Telephone/Fax (1) 250**] to schedule an
[**Telephone/Fax (1) 648**].
We also scheduled [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes [**Last Name (NamePattern4) 648**] to better assess
your diabetes. You have [**Last Name (NamePattern4) 648**] on Friday [**7-26**] at 3
pm with Dr. [**Last Name (STitle) 978**].
1. Hemodialysis [**Last Name (STitle) 766**], Wednesday and Friday. You should have
your PT and INR checked to assess whether your coumadin dose is
correct. Dr. [**Last Name (STitle) 1366**] will follow-up on this blood test.
1. Provider: [**Name10 (NameIs) 2975**] [**Name8 (MD) 2976**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2109-7-25**] 10:45
2. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2109-8-20**] 9:10
3. Provider: [**First Name4 (NamePattern1) 3520**] [**Last Name (NamePattern1) 3521**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2109-8-27**] 9:40
|
[
"507.0",
"042",
"585.6",
"250.00",
"333.94",
"428.0",
"518.81",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.20",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10395, 10401
|
3896, 7803
|
300, 342
|
10629, 10675
|
2808, 3873
|
11867, 13032
|
2466, 2484
|
8701, 10372
|
10422, 10608
|
7829, 8678
|
10699, 11844
|
2499, 2789
|
233, 262
|
370, 1704
|
1726, 2210
|
2226, 2450
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,998
| 109,866
|
42614
|
Discharge summary
|
report
|
Admission Date: [**2130-3-10**] Discharge Date: [**2130-3-24**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
weight loss and no appetite
Major Surgical or Invasive Procedure:
[**2130-3-16**]
Right DL PICC
[**2130-3-20**]
1. Laparoscopic reduction of hiatal hernia.
2. Repair of diaphragm with pledgets.
3. Suture repair of gastric perforation.
4. Peg tube placement.
History of Present Illness:
Mr. [**Known lastname **] is a pleasant 87 years old man, previously relatively
healthy, who developed anorexia and had a 15 lbs weight loss
over the past 6 weeks. He states that he had his last full
"real" meal about 6 weeks ago after which he "lost interest" in
eating. He specifically denies any problems with dysphagia, pain
with eating or swallowing, choking, food getting stuck, early
satiety, nausea or vomiting. He also denies any fevers or
chills, and continues
to have small bowel movements. Over the past 6 weeks he has been
only taking liquids to stay hydrated, no solid food, and has
lost at least 15 lbs as a result. He has a very mild shortness
of breath but in general aside from "not wanting to eat" denies
anything else that is bothering him at present.
He has visited his PCP several times and was finally referred
for admission to [**Hospital **] Hospital due to failure to thrive. He
had a CT today which shows a large left diaphragmatic hernia
with abdominal contents in the left chest, with organo-axial
volvulus. He received zosyn and Protonix 40 at [**Hospital1 **] and was
transferred here for further management of this complex surgical
problem.
Past Medical History:
PMH: afib, chf, HTN, High Cholesterol
PSH: midline incision for stone retrieval from ureter
Social History:
No tobb/etoh/drugs, retired professor of biology at a local
community college.
Family History:
non contributory
Physical Exam:
Temp: 98.5 HR: 89 BP: 100/62 RR: 20 O2 Sat: 97% RA
GENERAL [ ] All findings normal
[ ] WN/WD [x] NAD [x] AAO [x] abnormal findings: cachectic
man
HEENT [x] All findings normal
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[ ] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [ ] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[x] Abnormal findings: dry mucous membranes
RESPIRATORY [x] All findings normal
[x] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [x] No spine/CVAT
[x] Abnormal findings: decreased breath sounds at left lung base
CARDIOVASCULAR [x] All findings normal
[x] RRR [ ] No m/r/g [x] No JVD [ ] PMI nl [x] No edema
[x] Peripheral pulses nl [ ] No abd/carotid bruit
[x] Abnormal findings:
GI [x] All findings normal
[x] Soft [x] NT [x] ND [x] No mass/HSM [ ] No hernia
[x] Abnormal findings: well healed lower midline abdominal
incision
GU [x] Deferred [ ] All findings normal
[x] 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: poor historian
Pertinent Results:
[**2130-3-10**] 06:11PM WBC-10.6 RBC-3.58* HGB-9.3* HCT-28.0* MCV-78*
MCH-25.9* MCHC-33.2 RDW-18.0*
[**2130-3-10**] 06:11PM NEUTS-89* BANDS-0 LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2130-3-10**] 06:11PM PLT SMR-HIGH PLT COUNT-575*
[**2130-3-10**] 06:11PM PT-14.2* PTT-31.4 INR(PT)-1.3*
[**2130-3-10**] 06:11PM GLUCOSE-102* UREA N-19 CREAT-0.6 SODIUM-138
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-25 ANION GAP-18
[**2130-3-10**] 06:11PM ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-69 TOT
BILI-0.7
[**2130-3-14**] CXR :
Patient's condition required examination in upright sitting
position using AP frontal and left lateral views. The heart
shadow is
difficult to delineate in detail because of overlapping
mediastinal structures including a large left-sided hiatal
hernia. Significant cardiac enlargement is unlikely and the
pulmonary vasculature is not congested. Relative prominence of
the central pulmonary vessels is identified but more attenuated
appearance of the periphery does not demonstrate any evidence of
advanced CHF.
There are some old parenchymal scars in the apical area but no
active
abnormalities are seen. Bilaterally, the lateral pleural spaces
are blunted probably by pleural effusions mild-to-moderate
degree. There is a large sized hiatal hernia with typical
air-fluid level in retrocardiac position. No other pulmonary or
cardiovascular abnormalities can be identified. Our records do
not include previous chest examinations available for
comparison. An outside chest CT has been transferred in to our
PACS system and shows the presence of a large hiatal hernia.
[**2130-3-23**] CXR post left thoracentesis
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the hospital, kept NPO and hydrated
with IV fluids. Based on his symptoms and anatomy, repair of his
large paraesophageal hernia was recommended. Unfortunately he
became delirious after having low dose Ativan which was given
preoperatively to reduce his anxiety. He was taken to the
Operating Room for surgery on [**2130-3-15**] but immediately refused
the surgery when he arrived in the Operating Room. He appeared
confused and delirious, the surgery was cancelled and he
returned to the floor.
The Psychiatry service evaluated him and felt that the confusion
and delirium was prompted by Ativan in combination with poor
nutritional status and his age. At that point the patient wanted
surgery again. A decision was made to place a PICC line and
give TPN for 4-5 days prior to operating with the attempt to
help improve his nutritional status. A PICC line was placed on
[**2130-3-16**] and TPN began.
In the mean time he worked with Physical Therapy and had no more
episodes of confusion or delirium.
On [**2130-3-20**] he was taken to the Operating Room and underwent a
laparoscopic paraesophageal hernia repair with PEG tube
placement. He tolerated the procedure well and returned to the
PACU in stable condition. He maintained stable hemodynamics and
his pain was well controlled. Following transfer to the
Surgical floor he continued to make good progress. His pain was
controlled with Tylenol alone and his mental status was intact.
His TPN continued and eventually tube feedings were started and
well tolerated. He was maintained on 2 cal HN 1 can TID. His
TPN was weaned off [**2130-3-23**] and his PICC line was removed.
His chest xray on admission to the hospital was notable for
bilateral pleural effusions but his respiratory status was not
compromised. His effusions did increase in size and on [**2130-3-23**]
he has a left thoracentesis for 1 liter of serosanguinous fluid.
He tolerated it well and his subsequent chest xray demonstrated
no pneumothorax and a clear diaphram. He was breathing
comfortably off of oxygen and had room air saturations of 95%.
He continued to work with Physical Therapy who recommended that
he go to a short term rehab prior to returning home to increase
his mobility and endurance. From a surgical standpoint he
continued to do well. His post sites were healing well and his
PEG site was dry. After a long hospital stay he was discharged
to rehab on [**2130-3-24**].
Medications on Admission:
diltiazem ER 360', ramipril 5', lovastatin 40', lasix 40', asa
81', ? celebrex (unknown dose) -
Discharge Medications:
1. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] PRN
() as needed for hemorrhoid pain.
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. ramipril 5 mg Capsule Sig: One (1) Capsule PO once a day.
5. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for SBP < 100.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Milk of Magnesia 400 mg/5 mL Suspension Sig: Two (2) tbsp PO
at bedtime as needed for constipation.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Giant paraesophageal hernia.
Delirium secondary to medications
Severe protein-calorie malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting
-Increased shortness of breath
Pain
-Take stool softners with narcotics
-No driving while taking narcotics
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2130-4-4**] at 9:00 AM
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:[**2130-3-24**]
|
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"E939.4",
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"300.00",
"E928.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
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218, 247
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508, 1684
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9283, 9427
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1817, 1897
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,563
| 149,491
|
34758
|
Discharge summary
|
report
|
Admission Date: [**2153-7-14**] Discharge Date: [**2153-7-31**]
Date of Birth: [**2073-1-27**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
SDH
Major Surgical or Invasive Procedure:
1. Right Craniotomy for SDH
2. Gastric tube placement
3. Intubation and Mechanical Ventilation
History of Present Illness:
80 year-old woman with a past medical history significant for
emphasema, hypertension, and recent subdural hematoma s/p right
craniotomy who was transferred to the medicine intensive care
unit from the neurosurgery service for respiratory distress.
.
The patient was admitted at [**Hospital1 18**] as transfer from OSH with new
right subdural hematoma and left hemiparesis discovered after
the patient was found unresponsive at her [**Hospital3 **]
facility. The patient was intubated at the OSH, then admitted to
[**Hospital1 18**] [**7-13**], and underwent an emergent right craniotomy for SDH
evacuation. The patient was able to be extubated [**7-15**]. The
patient underwent a hiatal hernia repair and g-tube placement
[**2153-7-18**]. Tube feeds were started [**7-19**]. After starting G-tube
feeds and being positive 1.5L, the patient was found to be in
respiratory distress with thick white secretions suctioned. The
patient endorsed a cough. At the time she was afebrile, BPs
120-130/60-70, tachycardic 100-110s, RR 30, O2 sat 98% 35%
shovel mask. Patient was evaluated by MICU who felt her
respiratory distress was likely due to volume overload. The
patient was given 20mg lasix iv, then another 20mg lasix iv with
minimal improvement in respiratory function. Patient continued
to be tachypneic and was transferred to the medicine intensive
care unit team.
.
On presentation to T-SICU, temp 99.1, HR 120s, BP 119/57, RR 39,
O2sat 99% FM 15L. Patient was felt to still be volume overloaded
and in failure. BNP from am labs prior to transfer was 2161.
Patient was trialed on CPAP in an attempt to avoid intubation.
Patient respiratory rate fell to low 30s, and her use of
accessory muscles also decreased. The patient's blood pressure
dropped to 107/47, and her oxygenation was in the 80s. Patient
was somnulent, reported beign short of breath, denied any chest
pain or abdominal pain. The patient was intubated. The patient
was then transferred to MICU 6 for continued care.
.
Past Medical History:
Emphysema
HTN
Bilateral hip replacements
Hyperlipidemia
Osteoporosis
Social History:
resides in [**Hospital3 **] facility. no current smoking, EtOH.
per family, has smoked in the past.
Family History:
non-contributory
Physical Exam:
On Admission:
O: T: 97.5F BP: 109/37 HR: 58 R: 14 O2Sats: 100% FiO2 1
Gen: Intubated.
HEENT: Ecchymoses and swelling over left eye.
Neck: In hard collar.
Lungs: Transmitted sounds bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Recently chemically sedated. No response to
noxious stimuli.
Cranial Nerves:
Pupils equally round and sluggishly reactive to light, 2 to
1.5mm bilaterally. Unable to test VF or EOM. Corneals intact.
Face obscured by devices so cannot reliably comment on facial
symmetry.
Motor: Tone slightly increased throughout. Slight withdrawal of
right but not left upper and lower extremities.
Sensation: No response to noxious stimuli throughout.
Reflexes: B T Br Pa Ac
Right 2 2 2 1 0
Left 3 3 3 1 0
Toes upgoing bilaterally
.
On admission to MICU:
PE:
VS: temp 99.1 BP 128/57, HR 104, RR 25 intubated AC 16*350, 40%
FiO2, O2 sat 99%.
GEN: intubated, sedated
HEENT: AT, NC, PERRLA, no conjuctival injection, anicteric, OP
clear, MMDry, Neck supple, no LAD, JVP to ear
CV: Tachy regular, II/VI LSB
PULM: Poor air movement, tight, end expiratory wheeze
throughout, dullness/crackles b/l bases.
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL
NEURO: sedated, no asterixis
.
Pertinent Results:
Head CT([**7-13**])
FINDINGS: There is a large hyperdense subdural hematoma with
areas of
isodensity layering over the right cerebral convexity measuring
approximately 1 cm in greatest diameter. There is shift of the
normally midline structures by 10 mm (2, 15) indicating
subfalcine herniation. There is mild effacement of the right
lateral ventricle with expansion of the left temporal [**Doctor Last Name 534**]
concerning for trapped left ventricle. The quadrigeminal and
suprasellar cisterns are patent. Extensive calcifications of the
basal ganglia are noted bilaterally. Extensive periventricular
white matter hypodensities are noted and consistent with chronic
small vessel ischemic changes. A large amount of soft tissue
swelling is seen over the left periorbital soft tissues (2, 10)
and over the left calvarium. There is no evidence of acute
fracture. There is
opacification of the sphenoid sinus, left greater than right and
minimal
opacification of the left maxillary sinus.
Head CT([**7-14**])->Post-evac
NON-CONTRAST HEAD CT: There has been interval right frontal
craniotomy with evacuation of the previously seen right subdural
hematoma. Post-operative pneumocephalus overlying both frontal
convexities of the small amount of residual high-density
subdural blood is apparent. There is also a new focus of either
intraparenchymal hemorrhage within the right temporal lobe,
measuring 2.5 x 1.8 cm (2:7) - previously there was a small
amount of blood products in this region and this new finding may
represent blooming of a contusion. There is decreased shift of
the normally midline structures, with now 6 mm of leftward
midline shift (previously 10 mm). The ventricular size is stable
and there is no evidence of intraventricular blood. Extensive
periventricular hypoattenuation consistent with chronic
microvascular ischemic disease is unchanged. Basal ganglia
calcifications noted. There remains moderate opacification of
the sphenoid sinuses and ethmoid air cells. There is also new
orbital emphysema seen anterior and medial to the left globe.
Soft tissue swelling overlying the craniotomy site is within
normal post-operative limits.
Head CT [**7-15**]:
1. Interval increase in right inferior temporal parenchymal
contusion as well as slight increase in the right frontoparietal
extra-axial collection.
2. Stable degree of shift of the septum pellucidum.
3. Persistent orbital emphysema. The integrity of the orbital
wall is better assessed in the dedicated sinus CT.
.
Head CT [**7-27**]
1. Stable right subdural hematoma and right temporal parenchymal
contusion
with slight decrease in mass effect.
2. Resolving left temporal subdural hematoma.
3. Opacification of the sphenoid sinuses and mastoid air cells
most likely
due to intubation.
.
C-Spine CT([**7-13**])
IMPRESSION: No evidence of acute fracture. Severe degenerative
changes of
the cervical spine.
X-rays Lt Wrist([**7-13**])
FINDINGS: There is soft tissue irregularity and gas seen along
the dorsum of the hand. No radiopaque foreign densities are
seen. There are no signs for acute fractures. There is an old
healed fracture deformity of the fifth metacarpal. Degenerative
changes are seen, most prominent within the PIP joint of the
long finger, first IP and first CMC joint.
CT sinus/max/[**Last Name (un) **]:
1. Persistent intraorbital extraconal air, which could be
secondary to tiny nondisplaced superior orbital fracture.
2. Slight increase in right extra-axial collection as well as
right inferior frontal lobe parenchymal hemorrhagic contusion.
3. Redemonstration of mastoid air cells opacification as well as
fluid levels in the sphenoid sinus.
CT abd:
1. Relatively large hiatal hernia, which contains fundus and
proximal portion of the stomach. As the GE junction is not
visualized on this study, it is not clear whether this hernia is
a paraesophageal or a sliding type.
2. Chronic wedge compression fracture of the L3, T12, T11, and
T10.
3. Small bilateral pleural effusions and bibasilar atelectases.
4. Acute fractures of the left 10th rib.
.
CXR [**7-30**] -
There are low inspiratory volumes, lower than on [**2153-7-28**].
Otherwise, I doubt
significant interval change. Cardiomediastinal contours are
stable. There is
upper zone redistribution and diffuse vascular blurring,
consistent with CHF.
There is a small left effusion, with left lower lobe collapse
and/or
consolidation.
Osteopenia, old fracture of the left proximal humerus, and
degenerative
changes and thoracic spine compression fractures are again
noted, unchanged.
.
CXRs showed LLL opacification that improved over time,
consistent with aspiration pneumonia.
.
Labs:
[**2153-7-13**] 09:26PM PT-13.6* PTT-28.1 INR(PT)-1.2*
[**2153-7-13**] 09:26PM WBC-15.0* RBC-3.13* HGB-10.5* HCT-29.6*
MCV-95 MCH-33.5* MCHC-35.4* RDW-13.6
[**2153-7-13**] 09:26PM cTropnT-0.09*
[**2153-7-13**] 09:26PM GLUCOSE-105 UREA N-6 CREAT-0.4 SODIUM-129*
POTASSIUM-2.8* CHLORIDE-102 TOTAL CO2-18* ANION GAP-12
[**2153-7-14**] 04:28AM PHENYTOIN-11.5
[**2153-7-16**] transferrin 176
.
Labs on discharge:
WBC 10.4, HB 8.6, Hct 22.9, Plt 496
Na 143, K 3.3, Cl 110, HCO 25, BUN 20, Cr 0.6, Gluc 126
AST 43, AST 48, AP 106, T bili 0.2
.
Of note, patient had anemia throughout stay, was transfused one
unit on [**7-23**] and has stayed stable since then. Thought to be
from subdural bleed, not actively bleeding.
.
WBC peaked at 18 when pneumonia was diagnosed, has steadily gone
down since treatment started.
.
Transaminitis peaked with AST 86, ALT 63.
Brief Hospital Course:
Hospital Course on Neurosurgery service: ([**Date range (1) 79637**])
SDH: Patient was admitted and emergently underwent a left
craniotomy for an acute right SDH. She tolerated the procedure
well and was transferred to the SICU intubated. She was
monitored closely with Q1hr post op checks. She continued to
have right-sided hemiplegia stable from the time of admission.
A post-op CT showed typical post-operative changes with
decreased mass effect. Her neuro exam continued to improve and
she was consistently following commands, although her left side
remained plegic.
.
Hyponatremia: She was initially fluid restricted for a sodium
nadir of 120, which gradual increased to 135 without the need of
hypertonic saline or further fluid restriction.
.
L hand wound: A plastics consult was obtained to evaluate her
left dorsal hand/wrist wound. They recommended close
observation and [**Hospital1 **] dressing changes with Xeroform. Skin
grafting was not indicated.
.
C-spine: On [**7-15**] she was extubated successfully, and her c-spine
later cleared clinically.
.
FEN/GI: A Doboff feeding tube was attempted unsuccessfully on
[**7-14**]. On [**7-16**] a nasogastric tube was again attempted
unsuccessfully under fluoroscopic guidance. On [**7-17**] she had an
abd CT which showed a large hiatal hernia. On [**7-18**] she
underwent GTUBE placement by Dr. [**Last Name (STitle) **]. She tolerated the
procedure well, was extubated, and transferred to the step down
unit in stable condition. Tube feeds were begun 24 hours
post-op. A nutrition consult recommended probalance TFs at a
goal rate of 50cc/hr. Pt aspirated, became hypoxic, and was
transferred to the MICU on [**7-19**].
.
Hospital Course while in MICU ([**2153-7-19**] - [**2153-7-29**])
.
80 y/o female HTN, emphysema, s/p craniotomy for SDH evacuation
intubated for hypoxic respiratory distress, now with pneumonia
(etiology likely multifactorial -- aspiration PNA/pleural
effusions) and urinary tract infection.
.
# Respiratory Failure: Pt suffered from an aspiration PNA 2' to
TFs. Pathogen determined to be Hafnia Alvei in the sputum
(enteric GNR), treated w/ an 8 day course of Levaquin. She was
initially covered broadly for for HAP/VAP/aspiration PNA
(received 4 day course of Vancomycin (start date 7.21), 3 day
course of Zosyn (start date7.21), and 2 day course of Cipro
(start date 7.22).) Her respiratory distress was also likely
complicated by layering pleural effusions, followed by CXR and
treated w/ intermittent Lasix diuresis. Admitted w/ likely
aspiration 2' to TFs. Thought to have CHF as well(mildly
elevated BNP on admission, decreased while in ICU). COPD
exacerbation was less likely, but pt had a 3 day prednisone
burst that was completed on 7.20. she was also continued on Qvr
and nebulizers (albuterol as needed and iptratropium standing.)
Unlikely her distress was caused by PE (although this was of
concern initially) given neg LENIs, no ECG changes, no
hypotension. She was extubated successfully on 7.25 and was
suctioned aggressively and given robitussin to thin her
secretions. She was weaned to 2L NC and transferred to the
floor.
.
# Fevers: Patient had low grade temps and leukocytosis while in
ICU. Her BPs were stable to hypertensive and she did not require
pressors. Likely etiology aspiration PNA (Hafnia alvei on GS) +
E. coli UTI. Both H. alvei and E. coli were fluoroquinolone
sensitive. her differential showed an elevated Eosinophil count,
that trended down w/ d/c of Vanc/Zosyn. Initial c/f ACCY given
elevated LFTs, but no evidence of acute cholecystitis on RUQ
U/S. Elevated LFTs likely related to propofol and were trending
down at time of d/c. Speech and Swallow consulted on the patient
after extubation, and recommended a video swallow study. She
passed and can drink thin liquids and pureed solids and crushed
pills.
.
# Anemia: Pt had a hct drop on 7.21 down to 20.1, and PTT was
elevated. She had some tenderness on abdominal exam c/f a rectus
sheath hematoma, but her Abd CT was neg for internal bleeding.
Heparin SC was d/c-ed, pt was typed and crossed, and 1 U PRBCs
transfused. Her Hct and coags was checked frequently and
stablized ~24-25 for the remainder of her ICU admission. Stools
were guaiac negative.
.
# Sinus Tachycardia: Likely hypovolemia (CVP low, Echo shows
LVH, hyperdynamic systolic function w/ EF > 75%, TropT < 0.01)
vs. respiratory distress vs pain (post-op) vs infection vs.
agitation. Less likely PE, although patient has been in hospital
off heparin due to SDH. She had no pain, or tenderness in legs,
and negative LENIs. ST improved w/ Haldol administration. Pt was
found to have a TSH of 6.7 and free T4 of 0.84, left untreated
giving the likelihood of sick euthyroid syndrome. She was not
given ASA given hct drop. She was started at low doses of home
B-blocker at TID-QID intervals, which was gradually increased to
Metoprolol 50 [**Hospital1 **]. Albuterol was used whenever possible over
iptratropium to decrease non-specific B1 antagonization and
increased tachycardia.
.
# Subdural Hematoma, s/p evacuation. Rpt Head Ct on 7.21 stable.
Rpt Head Ct on 7.25 showed diminishing SDH and decrease in mass
effect. She was continued on Keppra 1500 mg IV BID.
Neurosurgery followed her while in the ICU.
.
# Elevated Lipase: No evidence of ACCY on RUQ U/S. Her LFTs
trended down prior to her d/c from the ICU.
.
# Metabolic Alkalosis: likely contraction + cerebral alkalosis
related to SDH. Also obligate rapid shallow breather. K was
agressively repleted to promote H+ shift into cells and decrease
bicarbonate reabsorption and ammoniagenesis in the renal PCT.
Her ABGs were followed and her diuresis goals were decreased as
tolerated. Her post-extubation ABGs were normal/slightly
alkalotic, and her HCO3 levels returned to baseline.
.
# Emphysema: 3 day steroid burst, followed by qvar +
nebs(albuterol prn /ipratropium) . She also received oral
prednisone again starting on [**2153-7-30**] for recurrent wheezing and
improved.
.
# Left Hand Avulsion Laceration: Plastics recommended xeroform
dressing changes [**Hospital1 **]
.
# Hypertension: stable. Metoprolol increased to home dose of 50
[**Hospital1 **] prior to d/c from ICU.
.
# Hyperlipidemia: held simvastatin, elevated LFTs
.
# Osteoporosis: held fosamax, given increase risk of GERD.
# Depression: hold paroxetine
.
Hospital Course on [**Hospital Ward Name 121**] 2 - general medicine unit:
.
# Subdural hematomas were stable. We reconsulted neurosurgery
to comment on her lack of R leg movement. They recommend repeat
CT scan which showed stable resolution of the subdural bleeds.
Did not see new stroke. Think her lack of leg movement may be
her new baseline and recommend follow up in two weeks. Continue
Keppra until then. Switched from IV keppra to PO keppra.
.
# Was tachycardic up to 150s. Treated with 500 cc bolus and
increased metoprolol to 75 mg [**Hospital1 **]. Think the tachycardia is
likely atrial tach due to her pulmonary disease. Has been
stable with HRs in 100s to 110s.
.
# For COPD started 5 day steroid course for COPD exaccerbation.
Also stopped albuterol and started zolpidex to avoid additional
B agonism in light of her tachycardia. Continued 8 day course
of levofloxacin. She has one day left after discharge to
rehabilitation.
.
# Other issues were stable. Trended her transaminitis which
were closer to normal. [**Month (only) 116**] be a result of her Keppra treatment.
Recommend checking in 4 days at rehab to make sure they are
not trending upwards again. If they are, would consider
changing siezure prophylaxis.
.
# Pt passed video swallow and we changed her diet. She does
need to keep the G tube at least 6 months but can begin pleasure
feeding. If taking sufficient POs, can readdress tube feed
amounts and adjust as caloric needs call for.
.
# Pt also was weaned off her NC oxygen and was saturating fine
on RA.
Medications on Admission:
Fosamax 70mg daily
Metoprolol 50 mg [**Hospital1 **]
Simvastatin 20 mg qhs
Paroxetine 20 mg daily
Albuterol INH [**Hospital1 **]
Spiriva 18mcg, 1 cap INH daily
Pulmicort 180mcg INH [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
5. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
6. Nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours).
8. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed for secretions.
9. Haloperidol 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day) as needed.
10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO
BID (2 times a day).
11. Prednisone 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily)
for 5 days: End date of steroids is [**8-3**].
12. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Month (only) **]:
One (1) neb Inhalation Q6H (every 6 hours).
13. Levofloxacin in D5W 750 mg/150 mL Piggyback [**Month (only) **]: One (1)
dose Intravenous Q24H (every 24 hours) for 1 days: End date for
total of 8 day course is [**8-1**]. .
14. Keppra 500 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO twice a day:
Please continue 1500 mg [**Hospital1 **] until patient has neurosurgery
follow up.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Primary Diagnosis:
Right SDH
Aspiration Pneumonia
Urinary Tract Infection
Hyponatremia
Malnutrition
.
Secondary Diagnosis
Dementia
COPD
Hypertension
Anemia
Discharge Condition:
vital signs stable, mildly tachycardic at baseline in 100s-110s,
saturating 95-100 on 2L, low 90s on room air. Pt is hard to
understand because of mumbling, is alert, oriented only at
times. Pt does not move R leg on command, moves all other 3
extremities.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] with a diagnosis of subdural
hematoma (a bleed in the brain) due to a fall you had at your
rehabilitation center. You had surgery to drain the bleed from
your brain, and had a tube placed in your stomach (A G-tube)
because you had large hiatal hernia and needed access so you
could eat. You also had an aspiration pneumonia resulting in
respiratory disgress that required you be mechanically
ventilated and a urinary tract infection. Both pneumonia and UTI
were treated with an 8 day course of the antibiotic levoquin.
.
General Instructions
?????? Take your pain medicine as prescribed.
?????? 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 and follow up with laboratory blood drawing as
ordered.
CALL YOUR SURGEON OR GO TO THE NEAREST ED 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.
- New aspiration event, shortness of breath, chest pain, or any
other symptoms that are concerning to you.
.
You are being discharged to a rehabilitation center to help you
regain your strength. They will be able also work with you on
your breathing and keep you on oxygen until you can breath well
without it.
.
You should return to the hospital as listed above and do not
hesitate to call if you have any questions.
Followup Instructions:
- You have an appointment with Dr. [**Last Name (STitle) 739**] on [**8-15**]
at 10:45 AM. Phone ([**Telephone/Fax (1) 88**].
.
- Please call Dr. [**Last Name (STitle) **], the surgeon who put in your G-tube and
fixed your hernia, and make an appointment within the next [**1-3**]
months. The phone number is [**Telephone/Fax (1) 6429**]. Thanks.
.
- Please call your PCP doctor and follow up about a week after
being discharged from rehab or when you would like to see her.
You can make an appointment while at the rehabilitation facility
if you would like.
Completed by:[**2153-7-31**]
|
[
"293.0",
"263.9",
"427.89",
"401.9",
"311",
"244.9",
"599.0",
"272.4",
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"041.4",
"294.8",
"507.0",
"V43.64",
"432.1",
"997.1",
"276.6",
"518.5",
"882.0",
"492.8",
"733.00",
"276.1",
"276.4",
"E888.9",
"553.3",
"285.8",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.08",
"99.04",
"38.93",
"38.91",
"01.31",
"43.19",
"96.72",
"96.6",
"96.04",
"53.80"
] |
icd9pcs
|
[
[
[]
]
] |
19348, 19391
|
9498, 17388
|
282, 379
|
19591, 19852
|
3966, 4999
|
21935, 22526
|
2621, 2639
|
17637, 19325
|
19412, 19412
|
17414, 17614
|
19876, 21912
|
2654, 2654
|
239, 244
|
9027, 9475
|
407, 2395
|
3021, 3947
|
5008, 9008
|
19431, 19570
|
2668, 2928
|
2943, 3005
|
2417, 2488
|
2504, 2605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,103
| 116,833
|
34845+57951
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-8-28**] Discharge Date: [**2145-9-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
1.Pacemaker placement
2. Surgical evacuation of Hematoma at pacemaker site
History of Present Illness:
The patient is a [**Age over 90 **]-year-old male with a past medical history of
atrial fibrillation, Hypertension and has a mechanical aortic
valve which was placed approximately 30 years ago for a "leaky"
aortic valve per patient. The patient is on home Coumadin
therapy for his atrial fibrillation and valve. He presented to
the emergency room complaining of multiple presyncopal episodes.
The patient describes these episodes as sudden occurences of
lightheadedness while sitting at the table. He would then set
his head down on the table and within seconds the symptoms would
resolve. These episodes occur at rest and never happen when the
patient is walking or up and about and more active. He denies
palpitations, chest pain, shortness of breath, and he has no
associated nausea or vomiting. These episodes have occurred [**12-27**]
x in the past week. No related orthopnea, PND, or edema.
.
Pt was recently admitted to the cardiology service for similar
episodes. It was felt that his episodes were due to bradycardia
secondary to severe HTN up to SBP 220s. The patient was started
on lisinopril, amlodipine and HCTZ. Upon discharge, HR ranged in
70s, SBP in 130s. Of note, the patient has been inadvertently
taking [**11-25**] his prescribed dose of amlodipine prescribed over the
past week.
.
In the ED, initial vital signs were: Temp 97.1 F, Pulse Rate 48,
BP 180/72 and RR 18, oxygen saturation 100% RA. His HR ranged
from 40-60 in slow atrial fibrillation. On telemetry, he
reportedly had occasional pauses of up to 3-5 seconds, but he
remained asymptomatic during these pauses.
.
On the floor the patient promptly triggered for marked nursing
concern and persistent HR < 40. Patient had multiple [**2-27**] second
pasuses on telemetry with narrow junctional escape beats.
Cardiology was consulted who recommended deferring temporary
pacing wire given elevated INR and history of mechanical valve.
Patient was transferred to CCU for closer observation and
monitoring overnight. On arrival to CCU patient denied chest
pain, SOB, PND, orthopnea, LE Swelling, syncope or other
complaints.
Past Medical History:
1. CARDIAC RISK FACTORS:: Hypertension
2. CARDIAC HISTORY: No interventions in past.
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation, on coumadin, no beta-blocker
- HTN
- Aortic valve replacement 30 years ago on coumadin
- Chronic Kidney Disease, Baseline Cr 1.5-1.8
- Emphysema by CXR - no O2 requirement, no medical therapy.
Social History:
Patient lives in [**Location 47**] with his wife in his own home. 45
pack year smoking history. Quit 30 years ago.
Family History:
non contributory
Physical Exam:
Vitals: T 97.8, BP 147/78, HR 59, RR 18, O2 sat: 98% on RA
Gen: Well appearing, NAD.
HEENT: NCAT.Sclera anicteric. No pallor or cyanosis.
Neck: Supple. No [**Doctor First Name **], no JVD.
Cardiac: no rubs/gallops, systolic murmur with audible
mechanical click
Lungs: Breathing comfortably at rest, No crackles or wheezes.
Abdomen: Soft, NT, ND. No masses. No rebound or guarding.
Extremities: Warm, well perfused. No edema. Good distal pulses.
Neuro: A+Ox3. CN 2-12 intact and symmetric. Grossly non focal.
Able to move all extremities.
Pulses: dopplerable LE pulses, femoral 1+ b/l, radial 2+ b/l
Carotids: Audible mechanical murmur, no bruits.
.
At time of discharge:
Pt's Exam is unchanged except for extensive erythema and edema
of left arm secondary to tracking of blood associated with pace
maker insertion. He has a palpable, but small hematoma
surrounding his pacer site which is bandaged.
Pertinent Results:
[**2145-8-28**] : EKG: Atrial fibrillation with bradycardia HR 40-50bpm,
left axis, no hypertrophy, mildly peaked T-waves, no acute ST-T
changes
.
TELEMETRY [**2145-8-28**]: Bradycardia with junctional escape, frequent
pauses of [**2-27**] seconds duration
.
[**2145-8-30**] TTE / ECHO : (no priors for comparison) The left atrium
is elongated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. A mechanical aortic valve
prosthesis is present. The discs appear to move, but the
transaortic gradient is higher than expected for this type of
prosthesis (unless very small prosthesis - details unknown). .
Mild (1+) aortic regurgitation is seen. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] The mitral valve leaflets and supporting structures are
thickened. No mitral stenosis. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is borderline pulmonary artery systolic pressure. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Well seated aortic valve prosthesis with slightly increased
gradient. Increased PCWP. Moderate mitral regurgitation.
Borderline pulmonary artery systolic hypertension.
[**2145-8-31**] CXR post-pacemaker placement: Single-chamber pacemaker
lead ending in the right ventricle. The rest of the study is
grossly unchanged compared to the previous scan.
[**2145-8-28**] 05:40PM BLOOD WBC-4.9 RBC-3.22* Hgb-10.8* Hct-32.3*
MCV-100* MCH-33.5* MCHC-33.5 RDW-13.9 Plt Ct-140*
[**2145-8-29**] 05:55AM BLOOD WBC-4.9 RBC-2.79* Hgb-9.9* Hct-27.5*
MCV-99* MCH-35.6* MCHC-36.0* RDW-13.8 Plt Ct-117*
[**2145-9-10**] 01:25PM BLOOD WBC-4.7 RBC-2.64* Hgb-8.8* Hct-25.7*
MCV-98 MCH-33.2* MCHC-34.1 RDW-17.6* Plt Ct-253
[**2145-9-11**] 05:50AM BLOOD WBC-5.7 RBC-2.74* Hgb-9.1* Hct-26.8*
MCV-98 MCH-33.0* MCHC-33.7 RDW-17.2* Plt Ct-240
[**2145-8-29**] 12:46AM BLOOD PT-23.1* PTT-35.7* INR(PT)-2.2*
[**2145-9-8**] 07:00AM BLOOD PT-15.2* PTT-29.7 INR(PT)-1.3*
[**2145-9-11**] 05:50AM BLOOD PT-23.6* INR(PT)-2.3*
[**2145-8-28**] 05:40PM BLOOD Glucose-87 UreaN-40* Creat-1.8* Na-138
K-4.9 Cl-103 HCO3-28 AnGap-12
[**2145-9-11**] 05:50AM BLOOD Glucose-86 UreaN-39* Creat-1.6* Na-142
K-4.5 Cl-109* HCO3-26 AnGap-12
[**2145-8-29**] 05:55AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2145-8-28**] 05:40PM BLOOD VitB12-791 Folate-GREATER TH
[**2145-9-9**] 05:10PM BLOOD Triglyc-54 HDL-50 CHOL/HD-2.7 LDLcalc-73
[**2145-8-29**] 05:55AM BLOOD TSH-2.5
[**2145-8-28**] 05:40PM BLOOD Digoxin-<0.2*
Brief Hospital Course:
In summary, Mr. [**Known lastname 11679**] is a [**Age over 90 **]-year-old male with PMH atrial
fibrillation, HTN, and s/p AVR on coumadin who presented with
pre-syncope, bradycardia and prolonged pauses on telemetry/EKG
and was referred to the EP team at [**Hospital1 18**]. Ultimately, after
evaluation it was felt that Mr. [**Known lastname 11679**] would benefit from a
pacemaker. He underwent surgery on [**2145-8-31**] and had a local
complication of a left anterior subclavian and anterior shoulder
region small hematoma after his procedure with some additional
ecchymotic tracking down his left arm. He was given a pressure
dressing and warm compresses for comfort after the procedure.
Throughout this time he had a slight dip in his Hct levels from
29-30 range to 25-26 range but was hemodynamically stable and
did not require transfusion. Discharge delayed by hematoma and
by subtherapeutic INR. Pt has a INR goal of 2.5 to 3.0 given his
atrial fibrillation, advanced age, hypertension, and mechanical
valve.
.
# Rhythm: pt persistently in Atrial fibrillation. Ventricular
rate maintained in the 60-70 range by pacer. Pt not orthostatic
or lightheaded. Will need to maintain INR of 2.5 to 3.0 given
Atrial-fib and valve. INR will be followed by PCP who followed
INR prior to this admission.
- Pt will f/u with Dr. [**First Name (STitle) 1075**] at [**Hospital1 **].
.
# CAD: No known CAD, no e/o active ischemia by EKG and no prior
infarcts on ECG.
- Ruled out MI, 2 sets cardiac enzymes negative
.
#Presyncope: Likely [**12-26**] to bradycardia. No syncope or falls.
- Negative w/u for other causes with U/A, UCx, CXR, ECHO, B12,
TSH level
.
# HTN: adequately controlled at the time of discharge in the SBP
range of 110 to 135
.
# s/p Aortic Valve Replacement: INR goal 2.5-3 as above
.
# Chronic renal failure: Cr at baseline of 1.5-1.8 during
hospitalization
.
# Follow-up: Pt has appt's with Cardiology and PCP. [**Name10 (NameIs) **] family
is actively involved in his healthcare and is aware of these
appts and the need for close follow-up of INR.
Medications on Admission:
HCTZ 25 mg
Amlodipine 10 mg dialy
Lisinopril 40 mg daily
Warfarin 2.5 mg daily
Lanoxin 0.125 mg daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q6H (every 6 hours): continue until you see
your opthamologist.
Disp:*1 tube* Refills:*2*
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q12H (every
12 hours) as needed for pain.
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): Stop taking after [**2145-9-15**].
Disp:*8 Capsule(s)* Refills:*0*
8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS
(once a day (at bedtime)).
9. Outpatient Lab Work
Please check INR, Hct on [**2145-9-13**] and call results to Dr. [**Name (NI) 79783**] office.([**Telephone/Fax (1) 79784**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Atrial Fibrillation and Bradycardia requiring pacemaker
placement
Mechanical AVR
Hypertension
Infected left tear duct
Discharge Condition:
The patient was stable at time of discharge with no complaints
of left pacemaker site pain, no chest pains, dizziness or
palpitations. Hematoma site improved.
INR 2.5
Hct 26.5
BUN 33 and Cr 1.5
Discharge Instructions:
You had a very low heart rate and required a pacemaker. Please
don't move your left arm over your head or tuck in your shirt
for the next 6 weeks. No lifting more than 5 pounds for 6 weeks.
Keep the bandage dry, no showers until after you see the [**Hospital **]
Clinic physicians at [**Hospital1 18**] for a follow-up pacemaker appointment
on [**2145-9-14**]. You can also follow-up with Dr. [**First Name (STitle) 1075**] for ongoing
pacemaker management. You may take a bath as long as the pacer
dressing stays dry. You had some bleeding around the pacer site
and into your left arm and needed some fluid and blood to keep
your blood pressure up.
.
New medicines: You can
.
Please stop these medicines: You can stop taking your previous
Lanoxin medication.
Followup Instructions:
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], MD Phone: [**Telephone/Fax (1) 6256**] Date/Time: 3:30pm on [**9-17**], please call the office if this time is not possible, but
you must see Dr. [**First Name (STitle) 1075**] at some point next week.
[**Hospital1 18**] EP Follow-up appointment : Please return to the [**Location (un) 436**]
of the [**Hospital 23**] Clinic Building at [**Hospital1 18**] on [**2145-9-14**] at 10am for
a follow-up appointment to check your pacemaker and hematoma.
.
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17234**], MD Phone: ([**Telephone/Fax (1) 79784**] Date/time: pt's family
will call for an appt. Please continue to follow your INR level
with your Coumadin therapy with a goal INR of 2.5-3.5.
.
Opthamology:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2145-9-13**]
2:30pm at the [**Hospital 18**] [**Hospital **] Clinic
Completed by:[**2145-9-20**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12814**]
Admission Date: [**2145-8-28**] Discharge Date: [**2145-9-12**]
Date of Birth: [**2053-6-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12815**]
Addendum:
Addendum to hospital course: After his pace-maker placement, Mr.
[**Known lastname 5554**] developed a hematoma which was initially managed with a
pressure bandage. This was not sufficient and the hematoma
continued to expand. This was associated with a gradual fall in
his hematocrit to a low of 21 from 31 on admission. Over the
course of his hosptalization, he received a total of 2 units of
blood. The hematoma was managed with a surgical evacuation of
approximately 200cc of clot and blood from the pace-maker
pocket. After this procedure, another pressure bandage was
placed and the patients hematocrit was stable at 26 for five
days prior to discharge. On discharge day, the incision was not
weeping blood.
At the time of discharge, pt was restarted on his home dose of
coumadin for atrial fibrillation and a mechanical valve; his
PCP's office was contact[**Name (NI) **] to ensure appropriate follow-up of
his INR. He was scheduled for follow-up in device clinic at
[**Hospital1 8**] and with Dr. [**First Name (STitle) **] (Cardiology) at [**Hospital1 12816**]
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12817**] MD [**MD Number(2) 12818**]
Completed by:[**2145-9-26**]
|
[
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"427.31",
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"996.72",
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icd9cm
|
[
[
[]
]
] |
[
"37.71",
"99.04",
"37.79",
"37.82"
] |
icd9pcs
|
[
[
[]
]
] |
13767, 13974
|
6870, 8940
|
274, 350
|
10243, 10439
|
3940, 6847
|
11249, 12675
|
2986, 3004
|
9093, 10009
|
10102, 10222
|
8966, 9070
|
12692, 13744
|
10463, 11226
|
3019, 3921
|
2561, 2587
|
223, 236
|
378, 2480
|
2618, 2836
|
2502, 2541
|
2852, 2970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,772
| 160,465
|
35219
|
Discharge summary
|
report
|
Admission Date: [**2110-3-21**] Discharge Date: [**2110-3-25**]
Date of Birth: [**2036-1-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 74y/o F with a PMH of CAD, COPD presenting with
dyspnea. The pt reported acute onset dyspnea starting the day of
admission. She denied CP. She was found to be tachypnic and
hypoxic with sats in low 90s on 3L NC. She was placed on NRB
with O2 sat increased to 100%. No N/V. Pt was noted to be
lethargic and confused.
.
Pt recently hospitalized [**3-12**] with acute cholangitis due to
choledocolithiasis She underwent urgent ERCP with stenting and
was treated with Cipro/flagyl.
.
In the ED, initial vs were: T 99.6 BP 133/81 P 114 R 22 O2 sat
100% NRB Patient was given Solu-medrol 125mg IV X1, [**Month/Day (4) 19188**],
[**Month/Day (4) **] 325mg X1. ECG Afib with RVR at 117bpm, NA, LVH with recp. ST
changes. CXR demonstrated left basilar atelectasis and probable
small left pleural effusion. No overt CHF. CTA Chest showed
pulmonary emboli involving the right main pulmonary artery,
right upper lobar/segmental pulmonary artery, and right middle
lobe segmental pulmonary artery. She was started on a heparin
gtt.
.
On arrival to the ICU, the patient is resting comfortably on 3L
NC. Denies CP, states dyspnea is improving. C/o B/L LE pain at
baseline.
.
Uneventful MICU course. HD stable on coumadin. ECHO w/o RV
strain. Should check w/ PCP prior to coumadin as this had not
been started for afib. LE U/S pending.
.
On transfer: She states she feels hungry. She does not know why
she is in the hospital. She denies CP/SOB. She states she feels
itchy. Unable to give further clarification of past medical
history.
.
Past Medical History:
#. CAD
- s/p cath previously with reported non-obstructive CAD
#. DM 2
#. Hyperlipidemia
#. Afib - patient not anticoagulated
#. COPD - FEV1 unknown
#. s/p PPM
#. Osteoporosis
- Chronic joint pain
#. GERD
#. Anxiety
#. GERD
#. Anxiety Disorder NOS
#. Dysphagia
#. Dementia
#. Depression
#. Hospital acquired PNA with respiratory failure/ICU stay
[**2109-11-21**]
#. Prior unknown abdominal surgery
- likely ventral (?incisional) hernia repair with mesh
Social History:
The patient is currently a nursing home resident at [**Hospital 745**]
Health Care Center.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-Contributory
Physical Exam:
On Admission:
Vitals: T: 98 (98.9) BP: 126/64 P: 96 R: 18 O2: 100% on 2L NC.
General: Alert, no acute distress, oriented to person, year but
did not know place or current president
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: bibasilar crackles, no wheezes, rales, ronchi
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, 1+ pulses, no clubbing, cyanosis or edema, + calf
tenderness R>L
Pertinent Results:
[**2110-3-22**] 12:00AM GLUCOSE-231* UREA N-25* CREAT-0.6 SODIUM-148*
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-31 ANION GAP-12
[**2110-3-22**] 12:00AM CK(CPK)-44
[**2110-3-22**] 12:00AM CK-MB-NotDone cTropnT-0.01
[**2110-3-22**] 12:00AM CALCIUM-8.6 PHOSPHATE-4.1 MAGNESIUM-1.9
[**2110-3-22**] 12:00AM WBC-8.8 RBC-4.19* HGB-12.9 HCT-41.4 MCV-99*
MCH-30.7 MCHC-31.0 RDW-15.5
[**2110-3-22**] 12:00AM NEUTS-85.3* LYMPHS-11.3* MONOS-3.0 EOS-0.3
BASOS-0.1
[**2110-3-22**] 12:00AM PLT COUNT-300
[**2110-3-22**] 12:00AM PT-14.9* PTT-150* INR(PT)-1.3*
[**2110-3-21**] 06:04PM PTT-150*
CT CHEST PERFORMED ON [**2110-3-21**]
Comparison is made with a prior chest CT scan from [**2109-11-11**] as
well as a prior
chest radiograph from [**2110-3-11**].
CLINICAL HISTORY: 74-year-old woman with dyspnea. Evaluate for
PE.
TECHNIQUE: MDCT was used to obtain contiguous axial images
through the chest
prior to and following the uneventful administration of 100 cc
Optiray IV
contrast. Multiplanar reformations were provided.
FINDINGS: A pacer device is noted in the right chest wall with
lead tips
positioned in the right atrium and right ventricle. Non-contrast
imaging
demonstrates coronary artery calcifications. Pneumobilia is
noted in the
upper abdomen.
There is an eccentric filling defect within the right main
pulmonary artery,
best seen on series 3, image 32, which is compatible with a
pulmonary
embolism. Please note recanalized areas within this filling
defect suggest
that this is a chronic pulmonary embolism. There is extension of
this filling
defect into the right upper lobar and anterior segmental
pulmonary arterial
branches. Recanalization through this region also suggests a
non-acute
pulmonary embolism. There is a filling defect also noted within
the right
middle lobe, medial segmental branch of the right pulmonary
artery. This
filling defect is occlusive and appears acute. The remainder of
the pulmonary
arterial branches appear patent. The aorta contains
atherosclerotic
calcification, though is normal in caliber. The heart is
enlarged without
pericardial effusion. There is no lymphadenopathy. The airway is
centrally
patent. There is bronchial wall thickening especially in the
right upper
lobe, which is unchanged from prior exam.
Lung windows reveal confluent ground-glass opacity in the lungs
which is most
apparent in the right upper lobe. This finding is unchanged and
is likely
related to advanced RB-ILD (desquamative interstitial
pneumonia). A nodule is
again noted in the left lower lobe on series 3, image 48, which
measures 6 mm.
Compressive atelectasis is noted at the lung bases bilaterally
in the lingula,
left lower lobe, and portions of the right lower lobe. There is
no pleural
effusion.
In the visualized upper abdomen, there is a small hiatal hernia
and
pneumobilia is identified within the liver. Pneumobilia is new
from prior CT
and clinical correlation is advised. Please note, patient has
prior ERCP
dated [**2110-3-11**] and findings are likely secondary to prior
sphincterotomy.
BONE WINDOWS: No suspicious lytic or blastic osseous lesion is
seen.
Degenerative changes are noted in the thoracic spine.
IMPRESSION:
1. Pulmonary emboli involving the right main pulmonary artery,
right upper
lobar/segmental pulmonary artery, and right middle lobe
segmental pulmonary
artery. Please note, there are likely acute-on-chronic pulmonary
emboli given
the eccentric nature of the filling defects with evidence of
recanalization
through portions of the filling defects.
2. Emphysema with parenchymal ground-glass opacities most
apparent in the
right upper lobe suggestive of advanced respiratory
bronchiolitis.
3. 6-mm left lower lobe nodule, for which followup in [**7-18**]
months is advised.
,
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is no ventricular septal defect. Right
ventricular chamber size is normal with borderline normal free
wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: No evidence of RV strain
.
LE U/S: Prelim: NO DVT
Brief Hospital Course:
.
On initial presentation to the [**Name (NI) **] pts vitals were T 99.6 BP
133/81 P 114 R 22 O2 sat 100% NRB Patient was given Solu-medrol
125mg IV X1, [**Last Name (LF) 19188**], [**First Name3 (LF) **] 325mg X1. ECG Afib with RVR at
117bpm, NA, LVH with recp. ST changes. CXR demonstrated left
basilar atelectasis and probable small left pleural effusion. No
overt CHF. CTA Chest showed pulmonary emboli involving the right
main pulmonary artery, right upper lobar/segmental pulmonary
artery, and right middle lobe segmental pulmonary artery. She
was started on a heparin gtt and admitted to the ICU. She was
also found to have a urinary tract infection.
.
Hospital Course by Problem:
.
# [**Name (NI) **] Embolism - Pt initially presented with dyspnea, HD
stable. Risk factors include immbolitiy and recent
hospitalization. She was started on a heparin gtt but was
subsequently changed to lovenox because of poor IV access. She
remained on this and was not bridged with coumadin until her PCP
Dr [**First Name (STitle) **] was contact[**Name (NI) **] to discuss any contraindications to
anticoagulation with coumadin. He felt she did not have any
known contraindications and would wish to start therapy and this
could be discontinued in the future should she sustain a fall.
She had LE ultrasound done for risk assessment which was
negative. She was discharged on lovenox 90mg SC BID with a
bridge to coumadin. She should remain on Lovenox until her INR
is at goal ([**3-11**])
.
# Atrial Fibrillation - Pt presenting with RVR in setting of
hypoxia and PE. Her Metopolol was titrated to 75mg [**Hospital1 **] with
improved rate control.
.
# Hypernatremia - Na 149 on presentation, total body overloaded
but likely intravascularly dry and was repleted with D5W with
improvement.
.
# Urinary Tract [**Name (NI) 52676**] Pt was noted to have a UTI growing
MRSA and PROVIDENCIA STUARTII - she was initially treated with
vancomycin and ceftriaxone but sensetivities returned which
showed the MRSA sensetive to bactrim and Providencia sensetive
to ceftriaxone. She will complete 10 days of bactrim and
cefpodoxime on discharge. Blood cultures showed no growth.
.
# COPD - FEV1 unknown, no current evidence of exacerbation - She
was continued on [**Last Name (un) **] outpatient regimen of prednisone 5mg [**Hospital1 **],
fluticasone, albuterol and atrovent
.
# CAD/CHF - Pt was ruled out for an MI, EKG w/o ischemic
changes. She was continued on her beta blocker. Her aspirin and
plavix were discontinued secondary to high bleeding risk with
lovenox/coumadin (after discussion with her PCP). Her statin was
continued. Lasix was continued per home dose.
.
# DM 2 -Pts glucose was elevated while in hospital. She was
started on NPH 5U QAM and 8U QPM. She was given additional
sliding scale insulin. This should be further titrated as an
outpatient.
.
# Hyperlipidemia - continued home statin
.
# Anxiety -Pt was continued on paxil and clonazepam PRN
.
#. Dysphagia - Pt remained on soft dysphagia diet per home
regimen (nursing home)
.
#[**Name (NI) 25730**] [**Name (NI) 80361**] Pts CT showed incidental pulmonary nodule. She will
need a repeat CT scan in 6 months.
Medications on Admission:
Tylenol 650mg PRN
[**Name (NI) **] 325mg daily
Metoprolol 50mg [**Hospital1 **]
Atorvastatin 40mg QHS
Fluticason-Salmeterol 100-50mcg 2 disk [**Hospital1 **]
Albuterol
Atrovent
Prednisone 5mg [**Hospital1 **]
Paroxetine 30mg QHS
Clonazepam 0.5mg [**Hospital1 **] PRN
Alendronate 70mg Q Sun
Novolin SS
Plavix 75mg QHS
Dulcolax
Fleet Enema
Colace
Furosemide 40mg tab daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1196**] - [**Location (un) 745**]
Discharge Diagnosis:
Pulmonary Embolism
Urinary tract infection
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for some difficulty breathing.
You were found to have a clot in your lungs. You were started
on a medication to help break up the clot and keep your blood
thin to resolve these clots. You will continue to take coumadin
for this medication and your blood will be drawn to check its
level.
.
You were also found to have an urinary tract infection. You
were started on a medication called bactrim and cefpodoxime to
treat this. You will need to complete a 10 day course.
.
Your other medications were adjusted.
Your Plavix was STOPPED
Your aspirin was stopped.
Your Metoprolol was increased to 75mg twice daily
.
If you have worsening shortness of breath, chest discomfort,
fevers, chills, worsening abdominal pain or other symptoms,
please return to the ER.
|
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17,239
| 156,279
|
26489
|
Discharge summary
|
report
|
Admission Date: [**2133-10-23**] Discharge Date: [**2133-11-2**]
Date of Birth: [**2069-3-26**] Sex: M
Service: MEDICINE
Allergies:
Ancef
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Presented for elective AV junction ablation, admitted for
respiratory arrest and flash pulmonary edema post-procedure.
Major Surgical or Invasive Procedure:
AV junction ablation.
History of Present Illness:
This is a gentleman with a long history of atrial fibrillation
which has been maintained fairly well on Dofetilide until
recently. He was noted upon interrogation of his device during
an electrophysiology clinic visit on [**2133-8-18**] to have an
increase in his atrial fibrillation burden from 1.3% to 4.2% of
the time. He was in atrial fibrillation at the time of his
visit and for the previous month. He has been noted to have an
increase in his serum creatinine level over the past year from
1.2 to 1.6. Therefore increasing his Dofetilide dose was
contraindicated. He was therefore referred for AV nodal
ablation.
.
Of note, at time of this admission he denies any symptoms
including palpitations, shortness of breath, lightheadedness,
dizziness, syncope or presyncope. He has been scheduled for
this procedure twice before and cancelled due to an elevated
INR; he has been off coumadin since [**2133-10-15**] and his INR was 1.9
the morning of the procedure.
.
Today he presented for AJV ablation in his usual state of
health. He received Diazepam 5 mg prior to procedure but no
further sedatives and minimal IVF (<50cc) during procedure; he
tolerated the procedure well, was able to lie flat without
event. While dressing in the recovery area, he became dyspneic;
while EP fellow was examining pt, he became cyanotic and, when
she asked him to lie back for a CXR and ABG, he became
unresponsive. Code Blue was called; he was intubated and an
emergent right femoral line was placed.
Past Medical History:
1. Cor pulmonale, chronic
2. CHF (diastolic dysfxn) EF >55%.
3. Chronic bronchitis on 3L home O2 at all times (FEV1 58 %
predicted with ratio 112%)
4. Home OSA BiPAP settings are 18 and 11 with 3 L of
supplemental oxygen during the day
5. HTN
6. Obesity
7. Pulm HTN
8. CRI-baseline creat 1.3-1.8
Social History:
He is married and lives with wife. [**Name (NI) **] smoked 2 PPD x35 years and
quit 15 years ago. He drinks 1-2 beers/week. He worked full-time
as quality engineer (mechanical engineer) wearing oxygen to
work, has not worked since his hospitalization in [**Month (only) 205**].
Family History:
His father is with DM, no heart disease in family, only his
brother has HTN.
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
VS: 101.7 82 116/54 A/C 20x500 FiO2 100% PEEP 5; sat 95%
Gen: obese white male, intubated and sedated
HEENT: PERRLA, eomi, OP dry
CV: S1, paradoxically split S2, no murmurs
Lungs: + crackles at bases bilaterally, otherwise bronchial bs
Abd: obese, s/nt. +bs.
Ext: 2+ pitting edema with chronic venous stasis changes.
Neuro: sedated, but moves all four extremities. Non-focal.
..
PHYSICAL EXAM AT DISCHARGE:
Pertinent Results:
LABS AT ADMISSION:
.
[**2133-10-23**] 11:28PM TYPE-ART PO2-91 PCO2-55* PH-7.37 TOTAL
CO2-33* BASE XS-4
[**2133-10-23**] 06:09PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2133-10-23**] 06:09PM URINE RBC-21-50* WBC-0-2 BACTERIA-MOD
YEAST-NONE EPI-0
[**2133-10-23**] 02:40PM GLUCOSE-185* UREA N-56* CREAT-2.1* SODIUM-138
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-34* ANION GAP-11
[**2133-10-23**] 02:40PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-132* TOT
BILI-0.9
[**2133-10-23**] 02:40PM CALCIUM-8.9 PHOSPHATE-6.0*# MAGNESIUM-2.5
[**2133-10-23**] 02:40PM WBC-13.7*# RBC-5.23 HGB-13.0* HCT-42.8 MCV-82
MCH-24.9* MCHC-30.4* RDW-17.1*
[**2133-10-23**] 02:40PM PLT COUNT-237#
[**2133-10-23**] 02:40PM PT-19.5* PTT-48.0* INR(PT)-1.8*
[**2133-10-23**] 07:15AM GLUCOSE-118* UREA N-55* CREAT-1.9* SODIUM-139
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-33* ANION GAP-14
..
EKG:
V-paced with rate 80, underlying is likely afib.
..
CXR AT TIME OF ADMISSION ([**2133-10-23**]):
FINDINGS: There is an endotracheal tube with tip approximately
3.5 cm cranial to the carina. There is a left, dual-lead
pacemaker with the lead tips positioned over the right atrium
and right ventricle. There is new, diffuse, bilateral pulmonary
opacity consistent with fulminant pulmonary edema. There are no
pleural effusions and the cardiomediastinal contour is normal.
The cardiac contour is obscured by the overlying pulmonary
edema. The soft tissue structures and bony thorax are normal.
IMPRESSION:
1. Diffuse, bilateral pulmonary edema.
2. Endotracheal tube with tip seen 3.5 cm cranial to the carina.
..
CXR ([**2133-10-28**]) LAT [**Month (only) **] AND PA:
IMPRESSION: Left decubitus chest as requested read in
conjunction with a
frontal chest radiograph performed 8:52 a.m., reported
separately, and prior chest radiographs dated [**10-26**] and
16. There is no appreciable right pleural effusion or
pneumothorax. Mild pulmonary edema is noted.
..
TTE ([**2133-10-24**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%). There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with depressed free wall contractility. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-11**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Tricuspid regurgitation is
present but cannot be quantified. There is severe pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
..
ABDOMINAL U/S ([**2133-10-24**]):
1. Cholelithiasis without evidence of cholecystitis.
2. Cirrhosis and moderate ascites, without evidence of focal
liver lesion.
3. Splenomegaly.
Brief Hospital Course:
In summary this is a 64 year-old man with h/o pulmonary HTN,
OSA, COPD on home O2 and BiPAP at night, cor pulmonale, CRI
(creat 1.5-2.0) in last year, and AF with RVR s/p PPM, now s/p
AVJ ablation. He presents with hypercarbic respiratory failure
in the setting of lying flat for EP procedure.
..
# HYPERCARBIC RESPIRATORY FAILURE:
Acuity of the event and CXR were c/w acute pulmonary edema,
although not clear what the inciting event may have been, and,
additionally, pulmonary edema generally causes hypoxic arrest
rather than hypercarbic arrest. Mucus plugging in a patient
with chronic COPD was also considered; aspiration was also in
the differential, although history of event and CXR did not
support either of these diagnoses.
.
He was diuresed several liters and slowly weaned off of the vent
to ventilator settings w/ mask and then to BiPAP on the second
day. His oxygen requirement slowly decreased with continued
diuresis as well as nebulizers and inhaled steroids for
treatment of his COPD. He was kept on his home BiPAP settings
at night.
.
He was seen by pulmonary and they recommended adding Diamox to
reverse the contraction alkalosis a/w Lasix therapy. Thus we
added acetazolamide to his regimen of Lasix and metolazone. We
have stopped the Diamox after three days of therapy and will
discharge him on Lasix 80 mg PO twice daily and metolazone 2.5
mg every other day.
..
# FEVER / PULMONARY INFILTRATE:
He spiked a fever to 102 on the third night after admission.
Sputum cultures (good sample) showed rare growth of E. coli and
K. Pneumoniae but given no predominant organism there was
unknown significance of this culture; both bacteria were pan
sensitive. There was a retrocardiac opacity on CXR concerning
for PNA, thus we started him empirically on high-dose
levofloxacin for hospital acquired PNA and his fevers resolved.
His seven-day course will end on [**11-4**].
..
# PUMP: He has diastolic CHF with preserved EF of 50-55%; at
home he takes lasix 80 mg PO bid and metolazone 2.5 mg once
daily. He appeared clinically volume overloaded with chronic
appearing swelling of the lower extremities and crackles on lung
exam. His dyspnea improved significantly w/ diuresis. We made
no changes to his outpatient metoprolol dosing. We are
continuing his Lasix dose and are decreasing his metolazone to
every other day dosing.
..
# RHYTHM: He is in AF s/p AVJ ablation with a ventricular-paced
rhythm of 80 BPM. We continued his metoprolol and discontinued
his outpatient diltiazem. D/t his underlying liver disease, we
decreased his coumadin dosing. His current regimen is 1 mg once
daily. He should have daily INR checks as he completes a
seven-day antibiotic course (levo will potentiate coumadin
activity) and should have QOD INR checks thereafter until he is
stabilized on a coumadin dosing schedule.
..
# ELEVATED INR / CIRRHOSIS ON ULTRASOUND: He was noted to have
an INR of 1.8-2.0 w/o having taken warfarin within a span of 12
days; his liver edge is hardened and palpable several edges
below the costal margin. His transaminases were within normal
limits, TBili and AP were only slightly elevated. A RUQ U/S was
read as cirrhosis. Serologies for hepatitis B were negative for
immunization or exposure; hepatitis C serology was negative.
Iron studies were not c/w hemachromatosis. He denied
significant alcohol consumption. Likely this cirrhosis /
synthetic dysfunction is the result of R-sided heart failure,
congestive hepatopathy, +/- non-alcoholic steatohepatosis. We
have scheduled him for an appointment in the liver clinic.
..
# PRE-DIABETES: Given his liver dysfunction and elevated
glucoses on morning labs, we checked HgA1c which came back at
6.3. We started him on insulin sliding scale and had nutrition
meet with him to discuss pre-diabetic diet. He may benefit from
metformin treatment in the future.
..
During the hospitalization, he was given GI prophylaxis during
intubation with an H2 antagonist; his INR was therapeutic on
coumadin so no DVT prophylaxis was indicated. He was seen by
physical therapy who recommended discharge to rehab.
Medications on Admission:
Spiriva 18 mcg 1 cap IH daily
Flovent 110 mcg 2 puffs IH [**Hospital1 **]
Diltiazem 120 mg 1 tab daily
Lasix 80 mg 1 tab [**Hospital1 **]
Metolazone 2.5 mg 1 tab daily
Metoprolol Tartrate 100 mg 1 tab [**Hospital1 **]
KCL 20 mEq 1 tab five times daily
Coumadin 2 mg Mon-Sat and nothing on Sun
O2 at 3 liters
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
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 for constipation.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for Rash.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO QOD ().
13. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once: Give
on [**2133-11-4**] for to complete course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Status post AV ablation and biventricular pacemaker placement
Flash pulmonary edema requiring intubation
Acute on chronic diastolic heart failure
..
SECONDARY DIAGNOSIS
Liver synthetic dysfunction / cirrhotic changes on ultrasound
Atrial fibrillation on coumadin
Chronic obstructive pulmonary disease on home oxygen
Cor pulmonale
Pulmonary hypertension
Obstructive sleep apnea on night-time positive pressure
ventilation
Pre-diabetes diet-controlled
Discharge Condition:
Vital signs stable. Afebrile. Satting well on home oxygen and
BiPAP requirement.
Discharge Instructions:
You were admitted because you had sudden influx of fluid into
your lungs after your AV ablation. This made it difficult for
you to breathe and you needed to be intubated in order to
maintain adequate oxygen delivery to your brain and body. We
gave you medications to help you get rid of excess fluid in your
body. As this fluid was removed your breathing improved and we
were able to remove the breathing tube. We continued to remove
fluid and your oxygen requirements gradually decreased.
..
We have made some changes to your medications. We added a
diuretic to help you lose fluid from your body. This is called
acetazolamide (Diamox) and should be taken at a dose of 250 mg
twice daily. We did not make any changes to your Lasix dose
(remains 80 mg twice daily) but we changed your metolazone dose
to 2.5 mg every other day.
You were started on a 7 day course of levofloxacin for
pneumonia.
..
For your heart, we stopped your diltiazem. Please continue to
take metoprolol at a dose of 100 mg twice daily. There were no
changes to any of the inhaled medicines that you take for your
lung disease.
..
One of the imaging tests of your abdomen showed that you may
have cirrhosis, or hardening of the liver. We have therefore
decreased your coumadin (Warfarin) dose, because the levels of
this drug are affected by liver function. We would like you to
follow-up in liver clinic. The scheduled appointment is listed
below.
..
Please weigh yourself every morning and call your doctor if you
weight increases by more than 3 pounds. Please adhere to a 2 gm
sodium diet. This will help prevent damage to your heart.
Followup Instructions:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2133-12-1**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2133-12-1**]
3:40
..
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2134-1-13**]
2:10
..
LIVER CLINIC follow-up: Dr. [**First Name8 (NamePattern2) 2943**] [**Name (STitle) 696**]. Phone:
[**Telephone/Fax (1) 2422**] Wednesday [**11-18**] at 2:30pm. [**Hospital **] Medical
Office building, Floor 8E.
Completed by:[**2133-11-2**]
|
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"V45.01",
"496",
"E879.0",
"516.0",
"327.23",
"403.90",
"278.00"
] |
icd9cm
|
[
[
[]
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[
"37.34",
"38.91",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
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12096, 12168
|
6397, 10508
|
385, 408
|
12680, 12765
|
3118, 6374
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|
12789, 14414
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2659, 3083
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3099, 3099
|
227, 347
|
436, 1933
|
1955, 2253
|
2269, 2549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,529
| 116,321
|
53489
|
Discharge summary
|
report
|
Admission Date: [**2130-10-3**] Discharge Date: [**2130-10-7**]
Date of Birth: [**2051-2-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None:
<BR><H3>PENDING ISSUES/FOLLOWUP:</H3>
<b>1. BLOOD PRESSURE:</B> The patient's systolic blood pressure
ranged 85-115. She was low even on 25 of metoprolol QID (at home
was on Toprol XL 200). She is being discharged on Toprol XL
100mg daily.
<br><b>2. CHF:</b> Her repiratory status was stable and she had
sats in the high 90s on her home O2 level of 2 lpm via NC. We
gave her fluids only very gently and did not diurese her. She
was fluid positive about 2L over the course of her hopital stay
but after transfer to the floor she had relatively equal Is and
Os with good urine output (around 1L on day prior to discharge).
We discharged her on her home dose of torseminde but held the
metolazone. She will see Dr. [**First Name (STitle) 437**] in clinic on [**2130-10-16**].
<br><b>3. Recurrent pleural effusion:</b>She is at her baseline
respiratory status. She will be seen in the interventional
pulmonology clinic to have a pleurex catheter placed to
facilitate
<br><b>4. Cancer:</b> The cells in the pleural fluid are more
likely breast than uterine. She was followed by her primary
oncologist, Dr. [**Last Name (STitle) **]. She was restarted on Arimidex, an
aromatase inhibitor. She will see Dr. [**Last Name (STitle) **] on [**2130-10-13**].<br>
History of Present Illness:
79 yo F with h/o chronic L pleural effusion, breast and uterine
CA in remission admitted from ED with AF with RVR, SBO and
leukocytosis.
Patient was found to be hypotensive at [**Hospital3 **] facility
and was brought in to ED. She was asymptomatic at the time.
In the ED, initial vs were: 98.8 118 109/63 16 96. Patient was
given 2L IVF. CT torso showed known pleural effusion and new
SBO. Surgery was consulted and recommended ex-lap for LOA which
patient refused. See surgery note for full details. Repeat VS
prior to transfer: 97.8 109 96/54 100% 2l 26.
On transfer to the unit, patient reports that she has some
worsening SOB over the last few days, but feels well now. On 2l
nc at baseline for restrictive lung disease. States she is
passing gas, last BM yesterday. Denies CP, fever, chills,
nausea, dysuria, HA, vision change or [**Location (un) **].
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 nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
H/o Stage 3 breast CA in [**2122**]
H/o endometrial CA s/p hysterectomy
Afib not on coumadin [**2-20**] falls
Restrictive lung disease on 2-3L nc at home
DCHF
s/p Pelvic Fx in [**5-/2130**]
Osteoporosis w multiple compression fx
OA
PPM for tachy/brady syndrome
H/o Non-sustained VT
Recurrent, refractory pleural effusions of unknown cause,
thought to be secondary to radiation. last tap on [**9-22**] showed
adeno
Hypothyroidism
Social History:
Lives alone in [**Hospital3 **]. Home health aide comes three
times per week. Remote tobacco use. Drinks two glasses of wine
each night to help her sleep.
Family History:
Two nieces with breast cancer, mother died of
CAD, father had emphysema.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2130-10-3**] 10:55PM
GLUCOSE-88 UREA N-19 CREAT-0.8 SODIUM-126* POTASSIUM-4.1
CHLORIDE-87* TOTAL CO2-31 ANION GAP-12
cTropnT-0.03*
proBNP-4913*
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-NEG
WBC-19.9*# RBC-4.61 HGB-15.6 HCT-45.1 MCV-98 MCH-33.9* MCHC-34.6
RDW-13.8
NEUTS-95.0* LYMPHS-2.0* MONOS-2.3 EOS-0.4 BASOS-0.2
ALBUMIN-3.3* CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.8
GLUCOSE-90 UREA N-25* CREAT-1.0 SODIUM-126* POTASSIUM-3.7
CHLORIDE-70*
CT CHEST/A/P
IMPRESSION:
1. Moderate sized left pleural effusion and small right pleural
effusion,
with enhancing pleural margins on the right, which may be
secondary to an
inflammatory or infectious process, though this appears similar
to prior
study.
2. Dilated small bowel loops, with decompressed and tethered
small bowel
loops in the pelvis, concerning for a small-bowel obstruction.
Locules of
extra-luminal air are noted in the mid abdomen.
3. Moderate amount of free fluid in the abdomen with new nodular
appearance
of the peritoneum, concerning for peritoneal carcinomatosis.
4. Subacute right inferior pubic ramus fracture, with
insufficiency fractures
of the sacral ala bilaterally.
5. Stable multiple compression deformities of the thoracolumbar
spine, as
detailed.
KUB ([**10-5**]):
IMPRESSION:
1. Unchanged bowel gas pattern consistent with partial SBO
2. Ascites.
3. Bilateral pleural effusions.
Pleural fluid (collected [**2130-9-22**]):
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma.
-Tumor cells are immunoreactive for Keratin AE1/AE3/CAM 5.2,
B72.3 and
[**Last Name (un) **]-31.
-Calretinin and WT-1 stain mesothelial cells in the
background.
- No immunoreactivity is seen for CEA, absorbed, Leu M1,
mammoglobin or
GCDFP.
-CK20 and TTF-1 show no immunoreactivity. Tumor cells are
positive for
CK7
Brief Hospital Course:
79 yo F with h/o Afib, breast CA, uterine CA both in remission
admitted from ED with Afib with RVR, SBO, leukocytosis, and also
with pleural fluid results from prior admission showing
adenocarcinoma.
# SBO: Unclear etiology but appears on CT to be [**2-20**] adhesions vs
peritoneal nodules suspicious for carcinomatosis. Pt denies N/V
before admission. She was seen by surgery and made it very clear
that she was not interested in surgery. When transferred to the
floor, she was passing flatus and has minimal output for her
NGT. It was removed on [**10-5**] and the patient tolerated a liquid
diet which was advanced and the patient had a bowel movement on
day of discharge. She did not have any nausea or vomiting.
# Leukocytosis: Though the patient was afebrile, she had an
elevated WBC count on admission and was started on levofloxacin,
vancomycin and metronidazole. Cultures were negative, there was
no evidence of infection and the WBC count trended down. Her
antibiotics were discontinued on [**10-6**] and her white count
continued to trend down and she remained afebrile.
# Atrial fibrillation: Has h/o paroxysmal AF, not on coumadin
given fall risk. She was rate controlled with IV fluids and
small amounts of beta blockers until she was taking POs and then
she was started on PO metoprolol.
# Hypovolemia: Patient was on torsemide and metolazone. She had
contraction alkalosis, hyponatremia and a concentrated appearing
CBC that resolved with IVF. She also was net fluid positive at
least 2L and was at her baseline respiratory status with
balanced Is and Os over the two days prior to discharge.
# Hypotension: The patient's systolic blood pressure ranged
85-115. She was low even on 25 of metoprolol QID (at home was on
Toprol XL 200). She is being discharged on Toprol XL 100mg
daily.
# CHF, chronic diastolic: Her repiratory status was stable and
she had sats in the high 90s on her home O2 level of 2 lpm via
NC. We gave her fluids only very gently and did not diurese her.
She was fluid positive about 2L over the course of her hopital
stay but after transfer to the floor she had relatively equal Is
and Os with good urine output (around 1L on day prior to
discharge). We discharged her on her home dose of torseminde but
held the metolazone. She will see Dr. [**First Name (STitle) 437**] in clinic on
[**2130-10-16**].
# Recurrent pleural effusion: She is at her baseline respiratory
status. She will be seen in the interventional pulmonology
clinic to have a pleurex catheter placed to facilitate
# Malignant Pleural Effusion: Effusion is chronic and recurrent
?????? but last tap on [**9-22**] had adenocarcinoma, staining pending. Pt
seen by Dr. [**Last Name (STitle) **] and aware of presence of malignant cells. The
cells in the pleural fluid are more likely breast than uterine.
She was followed by her primary oncologist, Dr. [**Last Name (STitle) **]. She was
restarted on Arimidex, an aromatase inhibitor. She will see Dr.
[**Last Name (STitle) **] on [**2130-10-13**].
# Elevated Troponin: Likely demand, trop flat in first 2 sets at
0.03 with normal CK. EKG without changes. Troponin trended down
to 0.02.
Medications on Admission:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Take through [**2130-10-1**].
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO twice a day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
10. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Medications:
1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1*
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*2*
5. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO twice a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: Small bowel obstruction
Secondary: malignant pleural effusion
Discharge Condition:
Good
Discharge Instructions:
Dear Ms. [**Known lastname 109973**],
It was a pleasure taking care of you again. You were admitted
because you may have had an obstruction in your bowel. This
resolved on its own. Your blood pressure was low and we are
sending you home on a lower dose of your blood pressure
medication.
The following changes were made to your medications:
START Arimidex
STOP Metolazone
STOP Toprol XL 200mg daily
START Toprol XL 100mg daily
Please take all other medications as prescribed. Please take
stool softeners and laxatives to maintain regular bowel
movements and prevent obstruction.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Call your doctor or 911 if you have severe nausea/vomiting,
shortness of breath, or for any other concern.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2130-10-13**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7634**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2130-10-13**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2130-10-16**]
1:30
[**10-20**], 9AM in Interventional Pulmonology Clinic on
[**Hospital1 **] 1, Dr. [**Last Name (STitle) 109974**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
|
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icd9cm
|
[
[
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,214
| 158,116
|
13613
|
Discharge summary
|
report
|
Admission Date: [**2125-11-21**] Discharge Date: [**2125-11-25**]
Date of Birth: [**2076-8-28**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Fish Product Derivatives / Codeine
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs [**Known lastname 24927**] is a pleasant 49 yo female with history of DMI,
kidney transplant, IgG deficiency who was transported from
[**Hospital Ward Name 23**] today by ambulance for hyperglycemia after presenting
for f/u for her neuropathy. The patient was at an appointment
for back pain when she was found to be symptomatic. She states
that she has been feeling fatigued for the past 3 weeks, feeling
"awful". She was feeling SOB, with general fatigue and malaise,
muscle aches, N/V, no fevers, + cough not productive of sputum.
She has not had her flu shot this year. She has been taking her
bactrim daily. She presented to an OSH for evaluation of her
respiratory complaints but states that she was not treated with
anything. Last night her BS was 124, over 500 this AM. There
was concern that her insulin pump had bbroken or patient states
that she may have run out of insulin in the setting of the power
outage. At her MD's office today, fingerstick was found to be
570.
In the ED, initial vs were: 98.2 88 96/39 20 91% 6L sat. EKG
showed no acute changes. Labs were notable for a VBG with pH of
7.25, anion gap of 25, glucose of 602, urine ketones and
creatinine of 1.5. She was given 1 L IVF, then 20mEq KCl/1L NS
over 2 hours, started on an insulin gtt, given morphine and
zofran for bilious vomiting. There was a concern for a small
focal opacity in LL lung field, therefore she was started on
ceftriaxone and levofloxicin.
On the floor, pt complaints of "pain everywhere" worse in her
feet and hip. She has no respiratory complaints and states that
her cough has improved. She also c/o nausea.
Past Medical History:
-DM1, last HbA1c 9%
-s/p renal transplant, baseline creatinine 1.5-1.7
-IgG deficiency on chronic immunosuppression, recurrent
pneumonias, asthma, and rhinitis, on IgG
-Depression
-History of appendectomy and tubal ligation
-Hx hospitalization and intubation in ICU for 6 wks, ARDS, pt
states current inhalers are left over from this episode and are
used infrequently
-anxiety/panic attacks since last ICU admission
Social History:
Married. Has an 18 year-old daughter. Smokes 1 pack per week x
4 months, history of use prior. Occasional alcohol use. Denies
street drug use. Five brothers who all use IVDU. One sister
committed suicide. Currently on disabiliy.
Family History:
Father: Stroke, hypercholesterolemia, skin cancer, prostate.
Substantial psychiatric history in family.
No family history of IDDM or immunodeficiency.
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.1 BP:106/52 P:81 R: 16 O2:100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly tender in lower quadrants, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Pertinent Results:
ADMISSION LABS:
[**2125-11-21**] 04:20PM BLOOD WBC-7.8# RBC-4.48 Hgb-13.0 Hct-40.9
MCV-91 MCH-29.1 MCHC-31.8 RDW-13.4 Plt Ct-268
[**2125-11-21**] 04:20PM BLOOD Neuts-80.9* Lymphs-13.3* Monos-4.0
Eos-1.6 Baso-0.2
[**2125-11-22**] 12:50AM BLOOD PT-12.7 PTT-32.1 INR(PT)-1.1
[**2125-11-21**] 04:20PM BLOOD Glucose-602* UreaN-36* Creat-1.5* Na-126*
K-4.5 Cl-87* HCO3-14* AnGap-30*
[**2125-11-21**] 04:20PM BLOOD Calcium-9.9 Phos-4.3 Mg-2.2
[**2125-11-22**] 01:02AM BLOOD Type-[**Last Name (un) **] pO2-61* pCO2-47* pH-7.26*
calTCO2-22 Base XS--5 Comment-PERIPHERAL
[**2125-11-21**] 04:28PM BLOOD Lactate-1.5
.
URINE:
[**2125-11-21**] 05:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017
[**2125-11-21**] 05:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
MICROBIOLOGY:
[**2125-11-21**] BCx: no growth
[**2125-11-21**] MRSA screen: negative
[**2125-11-22**] DFA: NEGATIVE FOR INFLUENZA A/B
CMV viral load: undetectable
.
STUDIES:
[**2125-11-21**] CXR: No acute pulmonary process.
.
Discharge:
[**2125-11-25**] 06:50AM BLOOD WBC-5.0 RBC-3.69* Hgb-10.4* Hct-31.6*
MCV-86 MCH-28.3 MCHC-33.0 RDW-13.6 Plt Ct-198
[**2125-11-25**] 06:50AM BLOOD Glucose-189* UreaN-13 Creat-1.2* Na-136
K-4.5 Cl-102 HCO3-31 AnGap-8
[**2125-11-25**] 06:50AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.0
[**2125-11-25**] 06:50AM BLOOD rapmycn-7.4
[**2125-11-21**] 09:25PM BLOOD HCG-<5
[**2125-11-23**] 06:55AM BLOOD Cortsol-12.5
[**2125-11-23**] 06:55AM BLOOD TSH-0.98
Brief Hospital Course:
Ms. [**Known lastname 24927**] is a 49 yo woman with hx of DM1, s/p renal
transplant, who was admitted with hyperglycemia, DKA.
# DKA: Admitted with with anion gap. In the ICU she was treated
with IVF and insulin gtt and her gap resolved. She was
hemodynamically stable and transferred to the floors. Etiology
of DKA is most likely pump malfunction. She did not have any
localizable infection. On the floor, pt's BG was well
controlled. [**Last Name (un) **] was consulted in the MICU started pt on
calorie counts. Her pump was interrogated by [**Last Name (un) 387**] and found
to be working. She was discharged on pump and will need close
follow up with PCP and [**Name9 (PRE) **].
.
#. Malaise: Infectious source was worked up but no focal source
of infection was identified. Pt did not have fever or
leukocytosis and cultures were negative. A CMV viral load was
undetectable and influenza was negative as well. Sirolimus
levels were checked and were wnl. Pt is on multiple sedating
medications, which certainly could be contributing to current
symptoms. Her oxycodone dose was cut in half and pt became less
sedated. In the future, stopping other medications should be
considered in outpt setting. pramipexole might be a good choice
in the future if she can tolerate stopping, as it can be quite
sedating.
.
#. S/p renal transplant: On admission her renal function was at
her baseline. She had no been seen by transplant service in
quite some time, so a consultation was placed. Sirolimus levels
were checked and within normal limits. Her mycophenalate dose
was changed to 500 mg [**Hospital1 **] and she was discharged on her regular
dose of sirolimus and bactrim.
.
# Chronic pain: Given pt's sedation and malaise, we decreased
her oxycodone dose to oxycontin 40mg [**Hospital1 **]. She tolerated dosage
change well and was discharged on all other home pain control
medications.
.
# IgG deficiency - pt was continued on weekly IgG
.
# EKG changes: with new q waves in inf leads, no evidence of
acute ischemia. Would consider outpatient echo/stress, will
defer to PCP.
.
# Depression: Pt denied suicidal ideations. She was continued
on home paxil
.
# Restless leg syndrome: Pt was continued on home pramiprexole.
Should consider stopping as outpt if can tolerate and malaise
persists.
.
# allergies: continued on montelukast
.
Transitional:
- outpt stress/ echo
- follow up with [**Last Name (un) **]
- follow up PCP, [**Name10 (NameIs) **] stopping other sedating medications
- follow up with transplant nephrologist for management of
immunosuppressant therapy
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) every four (4) hours as needed for shortness of breath
or wheezing (takes occassionally)
CLOBETASOL - 0.05 % Ointment - apply to hands two to three times
daily wrap/glove hands at night with severe eczema. no not use
on
face
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled qd to twice a day (takes
occasionally)
IBUPROFEN - 600 mg Tablet - one Tablet(s) by mouth three times a
day for 7-10 days
IMMUNE GLOBULIN (HUMAN) (IGG) [VIVAGLOBIN] - 16 % (160 mg/mL)
Solution - 30 ml weekly infused via pump as instructed (weekly
on tuesday)
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Cartridge - per pump
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
for 12 hours and remove for 12 hours daily as needed for pain.
Apply over painful areas.
LIDOCAINE HCL - 3 % Cream - apply to finger tips with severe
pain
twice a day
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth 1 hour PRN
anxiety
MIRTAZAPINE [REMERON] - 30 mg Tablet - 1 Tablet(s) by mouth
daily
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - 2 tablets
daily
OXYCODONE [OXYCONTIN] - 80 mg Tablet Sustained Release 12 hr - 1
Tablet(s) by mouth 6 hourly No Sub - No Substitution
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 10 mg-325 mg Tablet - 1 tab
TID
PAROXETINE HCL [PAXIL] - (Prescribed by Other Provider) - 20 mg
Tablet - Not sure of dose
PRAMIPEXOLE [MIRAPEX] - 0.5 mg Tablet - 2 Tablet(s) by mouth at
night - No Substitution
SIROLIMUS [RAPAMUNE] - 1 mg Tablet - 4 Tablet(s)(s) by mouth qam
(4 1mg tablets total 4mg/day)
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet -
1
Tablet(s) by mouth once a day
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use as
directed to test blood sugar at hoome for diabetes 8 times per
day
ONE TOUCH UL ULTRASMART SYSTEM - Kit - test strips for home
monitoring of blood sugar [**8-22**] brittle type one diabetes with
insulin pump
Discharge Medications:
1. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
TID PRN PAIN () as needed for pain.
4. sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. pramipexole 1 mg Tablet Sig: One (1) Tablet PO qhs ().
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*4 Tablet Extended Release 12 hr(s)* Refills:*0*
9. clobetasol 0.05 % Ointment Sig: One (1) application Topical
2-3 times daily.
10. immune globulin (human) (IGG) 15-18 % Range Solution Sig:
Thirty (30) mL Intramuscular once a week: 16% solution, weekly
on tuesdays .
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation q4hr PRN as needed for shortness of
breath or wheezing.
12. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
13. insulin lispro 100 unit/mL Cartridge Sig: One (1) per pump
Subcutaneous per pump: per pump.
14. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for dry itchy skin.
Disp:*qs qs* Refills:*0*
16. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for shortness of breath or wheezing.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
Fatigue NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 24927**],
You were admitted to the hospital for diabetic ketoacidosis.
This could have occurred because of a malfunctioning of your
insulin pump. We treated you with IV insulin and IV fluids.
Your sugars improved and you were started on a carb counting and
basal insulin regimen. It is important to make sure that you
are going to eat before taking your insulin to avoid
hypoglycemia. [**Last Name (un) **] was consulted and they helped put together
a new insulin regimen for you. You restarted your insulin pump
on the day of discharge with no problems. [**Name (NI) **] should monitor
your blood glucose frequently, and call your endocrinologist or
PCP if the values are abnormal (<70 more than twice or >300 for
greater than 12 hours).
During this hospitalization, we also worked you up for your
fatigue. We checked your thyroid function, adrenal function and
made sure that your immune suppressive medication levels were
not too high or too low. All of these tests came back negative.
We also monitored you for signs if infection and do not believe
that these symptoms are being caused by an infectious process.
On admission, we noticed that you are on multiple sedating
medications. We decreased your oxycontin dose to 40 mg twice
daily. I urge you to follow up with your PCP to work on
adjusting your medications even more. We also changed your
mycophenolate mofetil from two pills once per day to one pill
twice per day, as this could have been causing nausea. You had
some mild swelling of your right arm/hand, but an ultrasound
demonstrated no evidence of clot.
We have made the following changes to your home medications:
1. RESUME insulin pump
2. DECREASE Oxycontin 80 mg by mouth twice daily to oxycontin
40mg by mouth twice daily
3. CHANGE mycophenolate mofetil TO 500 mg Tablet Sig: One (1)
Tablet by mouth [**Hospital1 **] (2 times a day).
4. ADD camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for dry itchy skin.
5. ADD ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO
three times a day as needed for shortness of breath or wheezing
Please continue with all of you other home medications
It is important that you follow up with your PCP and [**Name9 (PRE) **].
Followup Instructions:
please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] and the [**Last Name (un) **] Center to
schedule a follow up appointment within the next week
|
[
"333.94",
"583.81",
"V58.67",
"250.13",
"996.57",
"250.43",
"V45.85",
"244.9",
"355.9",
"V42.0",
"279.03",
"401.9",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11469, 11475
|
5055, 7653
|
325, 332
|
11535, 11535
|
3521, 3521
|
14003, 14176
|
2697, 2849
|
9818, 11446
|
11496, 11514
|
7679, 9795
|
11686, 13343
|
2864, 3502
|
13361, 13980
|
272, 287
|
360, 1989
|
3537, 5032
|
11550, 11662
|
2011, 2428
|
2444, 2681
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,091
| 178,436
|
34798
|
Discharge summary
|
report
|
Admission Date: [**2145-12-27**] Discharge Date: [**2146-1-14**]
Date of Birth: [**2093-12-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal cancer with pelvic mass.
Major Surgical or Invasive Procedure:
[**2146-1-11**]: Direct laryngoscopy, Gelfoam injection of right vocal
cord and bilateral superior laryngeal nerve block.
[**2145-12-31**]: Flexible bronchoscopy with therapeutic aspiration.
[**2145-12-27**]: Exploratory laparotomy, pelvic washings, total
abdominal hysterectomy, bilateral salpingo-oophorectomy.
[**2145-12-27**]: EGD, transthoracic esophagogastrectomy ([**Last Name (un) 62523**])
with cervical anastomosis. Total abdominal hysterectomy.
History of Present Illness:
Mrs. [**Known lastname 3501**] is a 51-year-old female who was found to have an
advanced stage T3, N1 esophageal cancer. The patient underwent
adjuvant chemoradiation treatment with 5FU and Cisplatin for her
squamous cell cancer of the esophagus, and a repeat breast scan
showed inadequate response to preoperative chemoradiation. The
patient also had an impressive pelvic mass which was thought to
be an uterine fibroid, and a combined approach for her
hysterectomy and esophagectomy was scheduled for the patient who
was recently seen by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 1022**] from OB/GYN.
Past Medical History:
Esophageal cancer with pelvic mass.
Pulmonary Embolism
Right Vocal Cord paralysis and ineffective cough.
Right hydronephrosis s/p stent placement [**2145-8-31**] and removal
[**2146-1-12**]
Social History:
Married, 2 daughters, lives in [**Name (NI) 1456**]. Works for [**Doctor First Name **]
book distributor.
HABITS: Rare etoh. Smoked 1 ppd x 16 years, quit [**2126**].
Family History:
FH: [**Name (NI) **] aunt with "abdominal cancer". Father died of MI age 50,
and mother died of MS complications at age 51
Physical Exam:
general: frail appearing feamle in NAD.
HEENT: voice quality is raspy, cough is weak d/t vocal cord
paralysis which has now been medialized. Neck incision healing
well.
Chest: course breath sounds. weak cough.
COR: RRR S1, S2
Abd; abd incision healing. j-tube site w/ slight area of
erythema around tube.
Extrem: no edema
Skin: stage 2 on coccyx
neuro: weepy and emotionally fragile after prolonged hosp stay.
Pertinent Results:
CHEST TWO VIEWS [**2146-1-8**]
CLINICAL INFORMATION: Chest tube removal.
FINDINGS:
A left-sided chest tube has been removed. There is a tiny
residual left
apical pneumothorax. There is a patchy opacity in the lingula
and a small
residual left pleural effusion. There is a small left lower lobe
consolidation. There is a small right pleural effusion with
atelectasis at
the right base. A right large bore catheter terminates in the
superior vena
cava. Two access needles are present. There is a right middle
lobe
infiltrate, unchanged from prior study. Heart is top normal in
size.
Mediastinum is within normal limits. There is a faint right
upper lobe
infiltrate as well. None of these have changed since prior
study.
IMPRESSION:
1. Tiny residual left-sided pneumothorax status post chest tube
removal.
2. Multifocal patchy airspace opacities, unchanged since prior
study.
Brief Hospital Course:
Pt was admitted and taken to the OR for EGD, Esophagectomy,
hysterectomy and liver nodule resection on [**2145-12-17**]. An epidural
was placed at the time of surgery and bilteral chest tubes to
suction and an anastomotic JP in the neck.
Pt remained intubated and was admitted to the SICU for ongoing
management and ventilator support.
POD#0 HCT 23.6 w/ EBL in OR 800cc- rec'd PRBC. On peri-op levo
and flagyl.
POD#1 remained intubated w/ shallow rapid breathing, and low
TV's. Required aggressive pul tiolet. required volume
resusitation for low BP and low U/O.
HR remains 120's despite volume resusitation- started on
lopressor.
trophic tube feeds were initiated via J-tube.
POD#2 extubated w/ weak cough, voice and tacypnea, w/ shallow
rapid breathing. Required aggressive pul tiolet. Chest tubes to
water seal.
POD#3 remains tacypneic, tacycardic. on epidural but having
breakthru pain. Toradol added. remains on lopressor.
Desaturation to 80%. Stat CXR w/ PTX w/ chest tubes on water
seal. Placed back to sxn w/ resolution of PTx. O2 sats remained
low. CTA done which revealed bilat PE. started on IV heparin.
POD#4 bronch for pul tiolet- copious secretions in left lung.
Evaluated by ENT-right vocal cord immobile; left cord function
intact. chest tubes placed to water seal.
POD#5 HCT 24- rec'd PRBC. right chest tube placed to water seal
and then d/c'd w/ stable CXR
POD#6 tube feeds increasing to goal. epidural d/c'd. Pain
controled w/ PCA. Left chest tube d/c'd.- CXR w/ large PTX-
chest tube replaced and placed to sxn.
Swallow eval done w/ evidence of aspiration ? d/t cord
immobility vs overall weakness. strict NPO until video swallow
can be done.
POD#8 No evidence of bowel function. Remains on IV heparin for
PE. chest tube to water seal w/ stable CXR.
[**Name (NI) 1094**] PTT failing to be therapeutic on large amounts of IV
heaprin. thought to have possible Anti 3 deficiency- given FFP
w/ approp increase in PTT and decrease in IV heparin
requirement.
POD#9 GU evaulated patient re; urethral stents which were placed
for hydronephrosis during last admission. presently urien clean,
no flank pain. Per GU stents to removed as out pt. Pt
transferred to floor from ICU.
POD#10 tacycardia persists 150's- lopressor increased w/
improved HR. TF to goal. Chest tube clamping trial. urine
culture + for UTI- levaquin/vanco started.
POD#11 chest CXR w/o PTX- chest tube d/c'd.
POD#12 chest tube d/c'd w/ stable CXR.
POD#13 c/o abd pain, nausea, emesis. Hypoactive bowel sounds.
Pt refusing laxatives and enemas. vanco d/c'd and remained on
levaquin for UTI.
POD#14 KUB -full of stool. Tube feeds d/c'd. Iv hydration. Given
goltely via J-tube and soap suds enemas w/ good results after 12
hrs.
ENT injected right vocal cord for medialization. Heparin gtt
held for procedure and for 24 hrs post procedure.
Notified by nursing of stage II decub on buttocks.
POD#15 PT recommended long term acute care rehab upon d/c.
Right urethral stent d/c'd by urology.
POD#16 Heparin gtt resumed w/ therapeutic PTT.
POD17 evaulated by speech and swallow and passed for pureed diet
w/ thin liquids and meds crushed. No evidence of aspiration.
POD#18 heaprin gtt d/c'd. started on lovenox 50 [**Hospital1 **] and coumadin
3mg.
Medications on Admission:
hydromorphone, lorazepam, nystatin, Zofran, Protonix, Compazine,
docusate sodium, acetaminophen, Senokot
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q6H (every 6 hours) as needed.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as
needed.
3. Lorazepam 2 mg/mL Syringe [**Hospital1 **]: .5-1 mg Injection Q8H (every 8
hours) as needed for agitation.
4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
6. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: 3-5 MLs
Miscellaneous Q6H (every 6 hours).
7. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO BID (2 times a day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Four (4) mgs
Injection Q8H (every 8 hours) as needed.
10. port a cath
Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
11. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mls PO TID
(3 times a day).
12. port a cath
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Indwelling Port (e.g. Portacath), non-heparin dependent: Flush
with 10 mL Normal Saline daily, PRN, and when de-accessing, per
lumen.
13. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
14. Levofloxacin in D5W 750 mg/150 mL Piggyback [**Last Name (STitle) **]: 750mg
Intravenous Q24H (every 24 hours) for 6 days.
15. Warfarin 3 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Once Daily at
4 PM: monitor INR.
16. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day) for 14 days: via j-tube in elixir.
17. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily) for 14 days: via j-tube elixir.
18. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO BID (2 times a day).
19. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mls PO TID
(3 times a day) as needed.
20. regular insulin
per sliding scale
21. Enoxaparin 60 mg/0.6 mL Syringe [**Last Name (STitle) **]: Fifty (50) mg
Subcutaneous Q12H (every 12 hours): stop when INR therapeutic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Esophageal cancer with pelvic mass.
Pulmonary Embolism
Right Vocal Cord paralysis and ineffective cough.
Right hydronephrosis s/p R & L stent placement [**2145-8-31**] and R
removed [**2146-1-12**], L to be removed next week or as outpatient
Discharge Condition:
Deconditioned
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills, increased cough, or chest pain
-Develop nausea, vomiting, difficulty swallowing, abdominal pain
-Incision develops drainaged, increased tenderness or redness
-You may shower. No tub bathing or swimming for 6 weeks
-Head of the bed should be 30 degress at all times
-Humidified air
-pureed foods and thin liquids by mouth
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2146-1-27**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2146-2-1**] 11:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Follow-up with Dr. [**First Name (STitle) **] in clinic [**Telephone/Fax (1) 41**] call for an
appointment
Coumadin follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 79694**] [**Telephone/Fax (1) 79695**]. Please
call prior discharge from rehab for an appointment for their
coumadin clinic.
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] Urology [**Telephone/Fax (1) 3752**] for Left
renal stent removal
Completed by:[**2146-1-18**]
|
[
"707.05",
"150.8",
"591",
"707.03",
"599.0",
"285.1",
"518.5",
"478.31",
"415.11",
"218.9",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.62",
"31.42",
"65.61",
"68.49",
"57.32",
"99.05",
"43.99",
"99.04",
"50.29",
"33.23",
"96.6",
"31.0",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
9443, 9486
|
3321, 6547
|
317, 777
|
9772, 9788
|
2417, 3298
|
10270, 11267
|
1847, 1972
|
6702, 9420
|
9507, 9751
|
6573, 6679
|
9812, 10247
|
1987, 2398
|
241, 279
|
805, 1431
|
1453, 1645
|
1661, 1831
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,126
| 132,026
|
23429
|
Discharge summary
|
report
|
Admission Date: [**2124-8-21**] Discharge Date: [**2124-9-26**]
Date of Birth: [**2067-4-22**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Altered mental status and diarrhea
Major Surgical or Invasive Procedure:
Central line placement
Lumbar puncture
History of Present Illness:
This is a 57-year-old gentleman with CLL and large cell
transformation, s/p antigen mismatched URD SCT on [**2124-3-10**] (now
day +164), recently discharged from [**Hospital1 18**] to [**Hospital **] Rehab on
[**8-17**] and now re-admitted to 7 [**Hospital Ward Name 1826**] from clinic for diarrhea,
waxing/[**Doctor Last Name 688**] mental status, and electrolyte abnormalities. As
per physician at [**Name9 (PRE) **], patient had been having voluminous
diarrhea, and was overall "not doing well."
.
Mr. [**Known lastname **] was last admitted on [**2124-3-1**] (Tax Day, as he likes
to remind everyone) and went for antigen mismatched URD SCT
after Busulfan/ Cytoxan conditioning regimen. Although he
tolerated the transplant well, Mr. [**Known lastname 60074**] subsequent 5[**Hospital **]
hospital course was complicated by GVHD of liver and GI tract,
continous slow GIB, hematuria with BK viruria, adenoviremia,
altered mental status, and extreme deconditioning. All of his
acute issues had resolved by the time of discharge, and Mr.
[**Known lastname **] was transferred to [**Hospital1 **] for continued
rehabilitation.
.
In clinic pt appeared comfortable although depressed. His vitals
were stable. labs are at baseline except for lytes which will be
repleted. On arrival to the floor pt appears tired but otherwise
has no distress.
Past Medical History:
Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).
Patient underwent allo SCT on [**2124-3-10**] from MUD ([**7-27**], mismatch
at one HLA-A allele). The patient underwent a Busulfan/Cytoxan
conditioning regimen which did not cause neutropenia and he
tolerated it with only mild diarrhea. His initial transplant
proceeded without incident. His post-transplant course was
complicated by severe GVHD, febrile neutropenia, and viremia.
Social History:
Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol He has one
daughter who is 20-years-old.
Family History:
Notable for father who died of prostate cancer, with question of
lung involvement at the end. His mother had a history of MS and
one of his brothers is obese. An uncle with pancreatic cancer
and an aunt with breast cancer.
Physical Exam:
PHYSICAL EXAM:
98.4, 138/90, 92/min, 20/min,
General: appears comfortable at rest, no apparent distress
Neck: supple, no jvd
Cardiac: RRR, frequent pvc, no murmurs, rubs, or gallops
reduced air entry bilaterally
Abdomen: distended, but soft, no rebound/guarding/regidity
Extremities: 1+ edema bilaterally
[**Hospital Unit Name 60075**] EXAM:
GEN: intubated, sedated ill-appearing edematous gentleman, not
responsive to voice commands or painful stimuli.
HEENT: marked chemiosis bilaterall and extensive bilateral
scleral icterus, pupils equal and reactive to light
CV: regular rate, no murmurs appreciated
Lungs: coarse, ventilated breath sounds B/L, poor air mvmnt in
bases
Abd: markedly distended, hypoactive bowel sounds, soft
Ext: 4+ pitting edema B/L UE and LE up to sacrum, c/w anasarca
GU: extensive scrotal edema, foley in place w/ hematuria
draining
Skin: multiple areas of skin breakdown, skin oozing clear serous
fluid in upper extremities, multiple scattered ulcerations
Pertinent Results:
[**2124-8-21**] 03:15PM GLUCOSE-206* UREA N-19 CREAT-0.5 SODIUM-134
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-20* ANION GAP-14
[**2124-8-21**] 03:15PM ALT(SGPT)-139* AST(SGOT)-62* LD(LDH)-487* ALK
PHOS-511* TOT BILI-6.6* DIR BILI-4.9* INDIR BIL-1.7
[**2124-8-21**] 03:15PM ALBUMIN-2.5* CALCIUM-8.7 PHOSPHATE-1.8*
MAGNESIUM-1.9
[**2124-8-21**] 03:15PM TSH-0.15*
[**2124-8-21**] 03:15PM T4-4.2* T3-35* FREE T4-1.2
[**2124-8-21**] 03:15PM WBC-6.3 RBC-2.56* HGB-8.8* HCT-25.4* MCV-99*
MCH-34.2* MCHC-34.6 RDW-26.1*
[**2124-8-21**] 03:15PM NEUTS-87* BANDS-5 LYMPHS-1* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*
MRI [**9-20**]: Unchanged mildly compressive bilateral subdural
collections which appears simple based on signal
characteristics.
No acute infarct or abnormal intracranial enhancement
Brief Hospital Course:
Mr. [**Known lastname **] is a 57-year-old gentleman with CLL and large cell
transformation ([**Doctor Last Name 6261**]) s/p MURD SCT on [**3-10**], recently
discharged from [**Hospital1 18**] to rehab, now readmitted for increased
diarrhea, abdominal pain, and waxing/[**Doctor Last Name 688**] mental status.
He was admitted to the Intensive Care Unit following PEA arrest.
ALTERED MENTAL STATUS: Altered mental status was thought to be
of infectious etiology, though the CSF was negative for BK
virus, [**Male First Name (un) 2326**] virus, CMV, HSV, Herpes 6, and Toxoplasma. Adenovirus
was detected in the blood, less than 50,000 copies, and BK virus
was highly positive in the blood. Due to deterioration in
mental status and persistent altered state, the patient was
started on empiric cidofovir therapy at 5mg/kg IV weekly with
oral probenecid for renal protection, per ID recommendations,
for possible BK encephalitis pending the CSF results. An NG
tube was placed in the ICU for probenecid administration. His
acyclovir was discontinued since cidofovir was reinstituted.
Patient was also started on thiamine and folate. He received 2
doses of cidofovir on the [**8-25**] and [**9-1**].
Neurology was consulted for altered mental status and once
patient was released from ICU he underwent 24-hour video
monitored EEG. EEG was negative for seizure activity.
Despite treatment with cidofovir, mental status continued to wax
and wane. After which Infectious Disease recommended not to
continue therapy for BK viremia. Patient had periods of extreme
agitation during which time he would thrash around in bed and
strike his head against the side-rails. He would moan and cry
out--however when asked if he was in pain, Mr. [**Known lastname **] would
always shake his head "no." During this time, patient required
extensive sedation with anti-psychotics, benzodiazepines, and
pain medication. He was also restrained in bed. By the time of
transfer to the ICU on [**9-8**], Mr. [**Known lastname **] had become almost
unresponsive. On [**9-10**], He sustained PEA arrest and was
intubated, then sent to the [**Hospital Unit Name 153**] (see [**Hospital Unit Name 153**] course below).
BILATERAL SUBDURAL HEMATOMAS: A CT head from [**9-7**] showed small
bilateral hematomas. Most likely from trauma due to thrashing
around in bed with low platelets. A repeat head CT on [**9-9**]
showed no interval change in the hematomas. Neurosurgery
recommended no intervention at this time.
.
BK VIREMIA: Mr. [**Known lastname **] continued to have persistent BK
viremia. Despite two treatments with cidofovir, BK viral load
increased to 200,000. We began lowering immunosuppression, in
hopes that Mr. [**Known lastname **] could fight off the virus. Another BK
viral load is pending.
.
#HYPOTHERMIA-thought to be secondary to infection. Patient has
displayed this physiology with prior viral infectious. Possibly
secondary to an endocrine source, but patient is on steroids and
a cortisol stimulation test would be inaccurate. Thyroid studies
were consistent with a sick euthyroid picture. He was treated on
broad spectrum antibiotics in case this was a bacterial sepsis
picture. He was given warming blankets to maintain appropriate
temperatures.
The patient was readmitted to the ICU from [**Date range (1) 16255**] for
hypothermia, confirmed to 92.8 degrees Farenheit by rectal
temperature. He was warmed with a bair-hugger.
CLL S/P RICTHER'S TRANSFORMATION WITH ALLO SCT IN [**2-24**]: Disease
in remission. Immunosuppression continued, BMT team closely
following.
GI BLEEDING: Patient with long-standing heme positive stool,
however, GI bleeding increased in early [**Month (only) 359**]. His hematocrit
remained stable during these bleeding episodes. He underwent
flex sigmoidoscopy, which indicated bleeding from above the
level of the transverse colon. No other pathology was found at
the time. GI bleeding abated on its own.
.
#ELEVATED LFTS/TBILI: Related to GVHD, medications, and chronic
viral infection.
.
#ANEMIA/THROMBOCYTOPENIA: Secondary to
immunosuppresion/infection/GVHD. Patient's hematocrit remained
in the low 20s throughout admission, and he was transfused on a
"as needed" basis. We tried to keep his platelets above 30-40
in light of GI bleeding and subdural hematomas.
.
#DECREASED URINE OUTPUT: During first ICU course, patient had
mild decrease in urine output. He appeared intravascularly
depleted and was give fluid boluses throughout the day and
night. His urine output increased appropriately.
#HTN: Metoprolol was continued throughout admission.
.
[**Hospital Unit Name 153**] Course ([**2036-9-4**]): patient transferred to the ICU for
hypothermia, with an axillary temperature approx. 89oF on the
floor, he had previously been hypothermic with prior infections.
He was transferred to the ICU for rectal temperature monitoring
and rewarming. Overnight he was placed on a bair hugger and his
temperature increased to the 96 range rectally. The rectal
temperature probe was discontinued when he was found to be newly
neutropenic. After his initial warming his temperature remained
around 96 on the bair hugger and he was deemed medically stable
for transfer back to the floor. During his ICU stay he continued
to have worsening mental status, he was oriented to place, but
extremely agitated.
[**Hospital Unit Name 153**] Course ([**Date range (1) 60076**] ):
Early morning [**9-10**], the patient was found to have Cheynne
[**Doctor Last Name **] respirations and quickly lost a pulse. Epinephrine was
given once per ACLS protocol, and compressions were initiated on
the floor. Once the patient was identified as DNR, but
intubation and pressors okay, the compressions were stopped. The
patient returned to afib in the 150s with pulse. He was
intubated and transfered to the [**Hospital Unit Name 153**]. Finger BS was in the 130s.
He was briefly started on norepinephrine for blood pressure
support.
In the ICU, the patient was started on phenylephrine and
vasopressin and titrated off the norepinephrine due to atrial
fibrillation. He was started on an amiodarone drip, and he
quickly converted back to sinus rhythm.
Pan-CT showed new consolidation seen at the right and left upper
lobes near the apices, consistent with pneumonia, bilateral
small pleural effusions, left greater
than right, with right being new, small-to-moderate amount of
free fluid within the abdomen and diffuse anasarca. He was
intubated for inability to protect his airway and started on
broad spectrum antibiotics for coverage of pneumonia.
Throughout the remainder of his [**Hospital Unit Name 153**] course, his waxing and
[**Doctor Last Name 688**] mental status became a significant barrier to extubation.
The underlying etiology of his altered mental status was
unknown, as multiple blood and urine cultures exihibited no
microbial growth. Head CTs repeated on [**10-27**] and [**9-19**]
showed no interval change in his subdural hematomas and no new
intracranial hemorrhage. His mental status was inconsistent and
extubation was considered given his good FiO2 but concerns were
his inability to protect his airway. He was able to be extubated
since he seemed to have some improvement in mental status, with
some alertness and responsiveness to voice commands. His wife
had noted that over a period of a few hours he was able to say
"yes" and "no."
Unforunately, on [**9-15**] he developed progressive bradycardia,
followed by PEA arrest and was re-intubated by anesthesia, who
suctioned a mucus plus. After the 1st mg of epinephrine, he
regained his pulse. The arrest was thought to be due to mucous
plugging, although he had normal O2 sat prior to arrest. He had
a few episodes of bradycardia throughout the night and received
atropine. His neurologic function continued to deteriorate
without an obvious cause during his course. He suffered from
hematuria and melena and was seen by urology and
gastroenterology respectively.
A full infectious work-up for mental status change revealed no
acute pathology so MRI was performed.
MRI done on [**9-20**] did not reveal any additional abnormalities.
Neurology was consulted, repeat EEG was done on [**9-20**] but this
showed low voltage background consisting of diffuse slow
polymorphic delta activity. There were no focal lateralizing
lesions or epileptiform features noted that would be consistent
with seizure like activity. Neurosurgery was consulted regarding
subdural hematomas and whether there was utility in draining
them by Burr Hole; however, the risks of the procedure given Mr.
[**Known lastname 60074**] underlying comorbidities were far too great.
Due to his deteriorating clinical course and grim prognosis,
several family meetings were held and he was made comfort
measures only on [**9-25**]. A morphine drip was started and patient
was maintained on propofol for sedation and comfort. He was
extubated and passed in the presence of his family members,
including devoted wife and daughter on [**2124-9-26**] at 14:33.
Medications on Admission:
1. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
2. Saliva Substitution Combo No.2 Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. Oral Wound Care Products Gel in Packet Sig: One (1) ML
Mucous membrane QID (4 times a day) as needed for mouth pain.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for GVHD.
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please see attached sliding
scale.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QSUN ([**Doctor First Name **]).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ASDIR (AS
DIRECTED).
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
ASDIR (AS DIRECTED).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
17. Mycophenolate Mofetil 500 mg Tablet Sig: 1.5 Tablets PO Q 8H
(Every 8 Hours).
18. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO ONCE (Once) for 1 doses.
19. Micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous DAILY (Daily).
20. Rituximab 10 mg/mL Concentrate Sig: Seven Hundred-Fifteen
(715) MG Intravenous Give dose #4 (last dose) on [**2124-8-19**] for 1
doses: Please give 715mg on [**2124-8-19**].
21. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty Five (25) MG Injection QAM : Please give 25mg of
methylprednisolone sodium succ every morning.
22. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty (20) MG Injection Q PM: Please give 20MG of
methylprednisolone sodium succ every night.
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2124-9-28**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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19529, 19538
|
8066, 8453
|
303, 343
|
19589, 19753
|
7234, 8043
|
5983, 6209
|
19559, 19568
|
17141, 19506
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6239, 7215
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229, 265
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371, 1718
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8469, 17115
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1762, 5796
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5812, 5967
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,700
| 158,384
|
30191
|
Discharge summary
|
report
|
Admission Date: [**2200-1-14**] Discharge Date: [**2200-1-19**]
Date of Birth: [**2147-6-13**] Sex: F
Service: SURGERY
Allergies:
Keflex / Cephalosporins / Captopril / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
chronic renal failure
Major Surgical or Invasive Procedure:
living unrelated kidney transplant
History of Present Illness:
Patient is a 52F with end-stage renal disease secondary to
scleroderma. [**Known firstname **] noted the onset of renal disease in [**Month (only) 547**]
of this year when she presented to the emergency room with
shortness of breath and a rash, presumably that she initially
thought was related to allergic reaction to Keflex. At that
point in time, she was told she had renal failure. She had an
elevated [**Doctor First Name **] and an elevated anti-RNA polymerase I-III antibody.
She was rehospitalized after discharge for 11 days because of
fevers. Cultures were all negative and the fevers disappeared on
their own. She was initially dialyzed through a temporary line
in her right neck and subsequently through her right chest
tunneled catheter. In mid to late [**2199-7-5**], she started
peritoneal
dialysis after a ventral hernia repair and her tunneled line was
removed. She had one episode of peritonitis treated with
intraperitoneal vancomycin and oral rifampin. She only was
making 100ml of urine per day prior to transplant and was
thought to be a good candadite.
Past Medical History:
1. ESRD (likely [**3-8**] CTD) requiring PD
2. HTN
3. Scleroderma
Biopsy [**5-31**]: Mid to deep dermal sclerosis consistent with
scleroderma/morphea.
4. ?TTP requiring pheresis
5. BCC on back
Social History:
Lives at home with her husband and three children. She has
worked as a nurse in the [**Hospital3 **] doing ambulatory surgery.
Denies smoking, drinks alcohol only on weekends, denies drugs
Family History:
M: htn
F: htn, pancreatic ca
son: allergic esophagitis
no FH of CTD, scleroderma, other autoimmune disease, or renal
disease.
Physical Exam:
98.7 67 147/73 16 98%RA
pleasant, NAD
Chest: CTAB
CV: RRR, -MRG
Abd: soft/NT/ND, left abdominal peritoneal dialysis catheter
extrem: no edema
Pertinent Results:
[**2200-1-14**] 12:36PM BLOOD WBC-5.1 RBC-2.05*# Hgb-6.3*# Hct-19.5*#
MCV-95 MCH-30.6 MCHC-32.2 RDW-18.7* Plt Ct-221#
[**2200-1-18**] 05:41AM BLOOD WBC-6.7 RBC-3.87* Hgb-11.7* Hct-34.4*
MCV-89 MCH-30.1 MCHC-33.9 RDW-17.2* Plt Ct-289
[**2200-1-14**] 12:36PM BLOOD PT-14.8* PTT-32.0 INR(PT)-1.3*
[**2200-1-14**] 12:51PM BLOOD Glucose-131* UreaN-60* Creat-11.8*#
Na-140 K-5.2* Cl-100 HCO3-20* AnGap-25*
[**2200-1-18**] 05:41AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-137
K-4.0 Cl-102 HCO3-26 AnGap-13
[**2200-1-16**] 04:20AM BLOOD FK506-2.1*
[**2200-1-16**] 05:51AM BLOOD FK506-1.8*
[**2200-1-17**] 04:11AM BLOOD FK506-3.3*
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent living unrelated kidney
transplant, receiving her kidney from her husband. [**Name (NI) **]-op her
hematocrit was 19.5 and she was transfused with 2 units of
blood. The first days following her operation she had large
amount of urine output (16L immediately following surgery).
These losses were replaced using normal saline. Her creatinine
improved from 7.2 (pre-op) to 0.7 (post-op). She continued to
do very well post-operatively and her urine output began to
stabilize. She was easily walking daily, tolerating a regular
diet, and her pain was well controlled at the time of discharge.
She was discharged in good/stable condition.
Medications on Admission:
aspirin 81mg daily, Epogen weekly, flexeril 10mg [**Hospital1 **] PRN,
labetalol 400mg [**Hospital1 **], lisinopril 40mg [**Hospital1 **], norvasc 30mg daily,
dialyvite, renagel, protonix, valsartan 80mg [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 doses.
5. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO every twelve
(12) hours.
11. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO every twelve
(12) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
kidney transplant
Discharge Condition:
good/stable
Discharge Instructions:
Please continue to take your medications as instructed by the
transplant team. If you develop fevers, chills,
nausea/vomitting, or have questions or concerns please call
[**Telephone/Fax (1) 673**].
Followup Instructions:
Scheduled Appointments :
Provider [**Last Name (LF) **],[**Name9 (PRE) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2200-1-23**] 2:00
Provider IP,ROOM THREE IP ROOMS Date/Time:[**2200-1-23**] 2:00
Provider INTERVENTIONAL PULMONARY Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2200-1-23**] 2:00
.
Patient Discharge Plan :
Provider [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 673**] Call to schedule
appointment
|
[
"285.21",
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
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4904, 4910
|
2878, 3574
|
339, 375
|
4972, 4986
|
2232, 2855
|
5234, 5687
|
1927, 2055
|
3845, 4881
|
4931, 4951
|
3600, 3822
|
5010, 5211
|
2070, 2213
|
278, 301
|
403, 1485
|
1507, 1702
|
1718, 1911
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,074
| 162,201
|
50123
|
Discharge summary
|
report
|
Admission Date: [**2197-9-27**] Discharge Date: [**2197-10-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Elective admission for valvuloplasty
Major Surgical or Invasive Procedure:
Cardiac catheterization with Drug eluting stent to Left main
coronary artery
Cardioversion
History of Present Illness:
Mr [**Known lastname **] is a [**Age over 90 **] yo gentleman with history of aortic stenosis,
HTN, DM, HLD, PBD CAD s/p NSTEMI with LAD stent who was admitted
for elective cath/valvuloplasty in the setting of known AS and
increasing SOB over the past few weeks, and concern for
worsening AS by outside echo. Pt states that he has been
asymptomatic and denies SOB, chest pain/pressure, N/V or
diaphoresis. However, according to his home nurse, his exercise
tolerance has diminshed and although his mobility is even more
limited than usual due to shortness of breath. At present, he is
only able to walk [**12-23**] blocks before becoming short of breath. He
denies orthopnea however he sleeps on three pillows at night.
Currently he is pain free and asymptomatic.
.
He has been followed as an out-pt for his aortic stenosis. His
last echo on [**2197-9-21**] showed peak aortic gradient of 46, mean of
30.3 and [**Location (un) 109**] of 0.4 cm2. In the cath lab today, he was found to
have left main distal stenosis of 60-70% (borderline) and a
valve gradient 15-20 mm with calculated [**Location (un) 109**] of 1.2-1.3,
therefore valvuloplasty was deferred. A left main stent was
placed.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. He does endorse bilateral
LE edema.
Past Medical History:
CAD: [**5-26**]
Three vessel coronary artery disease.
Bilateral renal artery stenosis.
Diabetes
hypertension
hyperlipidemia
carotid artery disease- [**2193-3-12**] u/s: 50% [**Country **], 50-60% [**Doctor First Name 3098**],
External carotid artery stenosis > 50% on the left.
[**2182**] Left Carotid Endarterectomy
CRI
Social History:
Social History: Patient is married. His wife requires a lot of
care at home for which they have [**Name Initial (MD) **] visiting NP at least weekly
and visiting nurses as needed. His son is from out of town. The
patient is a survivor of the Holocaust. 7 p-y h/o tobb quit
[**2157**], has 2 sons, one is dentist. No EtOH.
Family History:
(?) [**Name (NI) 41900**] [**Name (NI) **] unclear
Physical Exam:
On discharge:
Tm 98 99-125/38-49, P 71-83, R16-18, 98% RA. + 175 in 24 hrs.
I=256/ O=200 since Midnight
Weight= 161.5 [**10-2**], refused this am
.
GEN: Alert, oriented, sitting comfortably in bed
PULM: CTA bilaterally
CV: RRR, 4/6 SEM at RSB, radiating to right carotid
ABD: soft, NT, ND, pos BS.
EXT: R ankle area is swollen, warm and errythematous, dependent.
right upper thigh with soft old hematoma extending from groin
(cath site) area, increasingly swollen with possibly newer
brusing closer to knee. Pt denies pain. 1+ edema to the ankle.
Slightly tender to palpation, no cords.
Pertinent Results:
[**2197-10-3**] 05:40AM BLOOD WBC-2.1* RBC-2.68* Hgb-8.0* Hct-25.6*
MCV-96 MCH-29.9 MCHC-31.3 RDW-17.5* Plt Ct-56*
[**2197-10-3**] 09:30AM BLOOD PT-20.3* PTT-61.3* INR(PT)-1.9*
[**2197-10-3**] 05:40AM BLOOD Glucose-90 UreaN-30* Creat-1.6* Na-141
K-4.0 Cl-103 HCO3-33* AnGap-9
[**2197-10-3**] 05:40AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.0
[**2197-9-27**] 05:15PM BLOOD Type-ART pO2-129* pCO2-47* pH-7.39
calTCO2-30 Base XS-3 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
.
[**10-1**] LE US
-No evidence of deep venous thrombosis in the right lower
extremity.
.
[**9-29**] RE US
1. No evidence of renal artery stenosis on the left. The right
side cannot
be evaluated and renal artery stenosis on this side cannot be
excluded.
2. Bilateral renal cysts.
.
[**9-28**] CARDIAC ECHO
Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. LV systolic function appears mildly-to-moderately
depressed (ejection fraction 40 percent) secondeary to
hypokinesis of the inferior and posterior walls. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. There are focal calcifications in the aortic arch.
The aortic valve leaflets are moderately thickened. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2196-8-8**], the right ventricle now appears somewhat
hypokinetic.
.
[**9-27**] CARDIAC CATH
1. Coronary angiography of this right dominant system
demonstrated left
main coronary artery disease. The LMCA had an 80% distal
stenosis. The
LAD and LCX had diffuse luminal irregularities. The RCA was
known to be
occluded and not injected.
2. Resting hemodynamics revealed severely elevated filling
pressures
with a LVEDP of 40 mmHg and a RVEDP of 24 mmHg. There was
severe
pulmonary arterial hypertension with a PA pressure of 75/34
mmHg. There
was systemic arterial hypertension with a central aortic
pressure of
154/64 mmHg. The cardiac index was normal at 2.5 L/min/m2. The
mean
gradient across the aortic valve was 15 mmHg. The calculated
aortic
valve area was 1.0 cm2.
3. Successful PTCA and placement of a 3.5x18mm Cypher
drug-eluting stent
were performed in the LMCA. The proximal edge covered the LMCA
ostium.
Final angiography showed normal flow, no apparent dissection,
and no
residual stenosis. (See PTCA comments.)
.
FINAL DIAGNOSIS:
1. Left main coronary artery disease.
2. Placement of a drug-eluting stent in the LMCA.
3. Moderate aortic stenosis.
4. Biventricular diastolic dysfunction.
5. Severe pulmonary arterial hypertension.
Brief Hospital Course:
[**Age over 90 **] yo gentleman with hx of AS, CAD, s/p cath with LAD stent
placement, admitted for management of AS and cardioverted for
afib.
.
# Coronary Artery Disease: Mr [**Known lastname **] has a history of CAD with
stent placement to the LAD [**3-27**] and known RCA occlusion. He does
not have any recent history of CP or pressure and ST depressions
on EKG appear to be chronic. Cath showed LM 80% lesion, rec'd
DES with good result. He will be continued on aspirin and
plavix on discharge and will need to take for at least one year.
.
# Acute on chronic systolic congestive Heart Failure: Volume
overloaded on exam with scrotal and peripheral edema. PCWP
elevated at 40. Lasix gtt initially to diurese. Pt then changed
to furosemide PO that was changed back to Torsemide [**Hospital1 **] on
discharge. Note that this is an increased dose for pt and he
should be monitored for signs of dehydration. Atenolol changed
to Metoprolol XL for CHF. ACE/[**Last Name (un) **] not started because of low
blood pressures after diuresis. This can be addressed by pts
outpt cardiologist. Pt should do daily weights and follow a low
Na diet.
.
# Aortic Stenosis: While ECHO [**2197-9-21**] showed severe stenosis,
cath here demonstrated only moderate area 0.96 and valve
gradient 15.01 therefore valvuloplasty was deferred. EF 45% on
repeat ECHO.
.
# Atrial Fibrillation: Was transiently in AF and cardioverted
into NSR. Started on Amiodarone to keep in NSR. He will need
PFT's, TFT's and LFT's as an outpt to with new amiodarone
initiation. Heparin gtt was started and transitioned to Coumadin
for 1 month course. His INR as 1.9 on discharge and his coumadin
dose was 5 mg, decreased to 4mg on [**10-4**]. His INR should be
checked again on [**10-5**].
.
# Pancytopenia: Patient has prior leukopenia and
thrombocytopenia. New anemia since cath in mid 20's although
this is close to pts baseline. Pt transfused 2 units while
inpatient. He has a large resolving hematoma on his right upper
thigh and had some scant rectal bleeding from anal fissure, now
resolved. Hct on d/c 28.
# Renal artery stenosis: on recent US, no stenosis was seen on
the left side. Right side unable to be evaluated. No further
action required at this time given that no evidence of bilateral
disease. Good BP control on current meds.
.
# Diabetes Type 2: Blood sugars were high here, his NPH/Regular
insulin was continued as at home. Likely some of these high
numbers were done post prandial. We will not adjust his insulin
at this time but FS should be followed at home.
.
#Lower extremity pain/edema: DVT ruled out with LE doppler.
Likely thrombophlebitis in right medial ankle area, On Ceflexin
TID and improving. Pt will need to continue Cefelexin for 5 more
days (7 days total). His legs should be elevated as much as
possible and Terbenafine should be applied to toes to treat
fungal infection twice daily.
Medications on Admission:
MEDICATIONS: confirmed with his home nurse, [**Doctor Last Name **]
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) AM 18-24 in eventing
13. Nitro PRN
14. 80 mg Lipitor q day
15. Plavix 75 mg daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop taking unless Dr. [**Last Name (STitle) **] tells you to.
Disp:*30 Tablet(s)* Refills:*11*
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Do not stop taking unless Dr. [**Last Name (STitle) **] tells you to. .
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for dry, pruritic legs.
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Change to 200 mg daily on [**10-5**]. .
Disp:*30 Tablet(s)* Refills:*2*
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days: Stop taking on [**10-9**].
Disp:*15 Capsule(s)* Refills:*0*
12. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 2 weeks.
Disp:*1 tube* Refills:*0*
13. Outpatient Lab Work
Please check INR, Hct and chem 7 on [**10-5**]. Call Results to Dr. [**Name (NI) 80071**] office at [**Telephone/Fax (1) 5768**].
14. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) units Subcutaneous before breakfast: 18-24
units before dinner. .
15. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO twice a day.
17. Torsemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Acute On Chronic systolic Congestive Heart Failure: Not on
ACE/[**Last Name (un) **] because of Hypotension
Paroxysmal Atrial Fibrillation
Myelodysplasia
Diabetes Mellitus Type 2
Hyperlipidemia
Aortic Stenosis
Peripheral Vascular Disease
Coronary Artery Disease
Discharge Condition:
stable
weight= 161.5 kg
BP= 125/49
HR= 71-83
O2 sat 98% RA
Discharge Instructions:
You had a catheterization which showed severe aortic stenosis
but did not need a valvuloplasty. A blockage was found in the
left main coronary artery and was stented with a drug eluting
stent. Do not stop taking Plavix of aspirin for one year to keep
the stent open. No baths for 3 days, you may shower. Please
follow the bruise on your right thigh for signs of a growing
bruise.
.
Medication changes:
1. STOP taking Omeprazole
2. START taking Ranitidine daily to prevent heartburn
3. STOP taking Atenolol
4. START taking Metoprolol XL to slow your heart rate
5. START Terbenifine twice daily for 2 weeks to treat the fungal
infection between your toes
6. Contiinue Plavix (Clopodigrel) to prevent the stent from
clotting off. Take this every day for one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**] or stop taking Plavix unless Dr. [**Last Name (STitle) **] tells you to.
7. Take 325 mg Aspirin daily. Take this every day for one year,
do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) **]
tells you to.
8. START Amiodarone. Take three times a day until [**10-5**], then
change to 200 mg once daily on [**10-6**]. This medicine keeps you in
a regular rhythm.
9. START Warfarin for one month to prevent blood clots that can
lead to a stroke. You will need to have your coumadin level
(INR) checked on Wednesday [**10-5**] and Dr. [**Last Name (STitle) **] will tell you how
much coumadin to take from then on.
10. Take [**Last Name (LF) 22509**], [**First Name3 (LF) **] antibiotic, to treat the infection near
your right ankle.
11. Increase Torsemide to 20 mg Twice daily
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet, information was given to you about
this at discharge.
Fluid Restriction: 1.5 liters
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**Name8 (MD) **] MD Phone: [**Telephone/Fax (1) 42391**] Date/Time: Pt seen by NP
at home.
Nurse Practitioner: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]: [**Telephone/Fax (1) 104629**]
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) 1730**] R. Phone: [**Telephone/Fax (1) 5768**] Date/time: Friday [**10-6**] at 12:30pm.
|
[
"440.1",
"401.9",
"272.4",
"427.31",
"428.23",
"424.1",
"238.75",
"427.32",
"414.01",
"250.00",
"451.0",
"428.0",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"00.40",
"37.23",
"00.66",
"99.04",
"99.62",
"88.56",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
13097, 13183
|
7071, 9964
|
299, 392
|
13489, 13550
|
3541, 6829
|
15516, 15934
|
2865, 2917
|
11068, 13074
|
13204, 13468
|
9990, 11045
|
6846, 7048
|
13574, 13956
|
2932, 2932
|
2947, 3522
|
13976, 15493
|
223, 261
|
420, 2163
|
2185, 2508
|
2540, 2849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,657
| 138,597
|
14459
|
Discharge summary
|
report
|
Admission Date: [**2194-6-3**] Discharge Date: [**2194-7-4**]
Date of Birth: [**2123-8-19**] Sex: M
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 496**] presented to [**Hospital3 418**] Hospital on [**2194-5-30**] acutely short of breath.
He had a right chest tube placed for a pneumothorax. After
placement of the this chest tube, he had a persistent air
leak and on the 7th developed subcutaneous emphysema. On
arrival to [**Hospital3 417**] Hospital, he had supraventricular
tachycardia and eventually ruled in for a myocardial
infarction with a peak CK of 330 and a troponin of 3.7. His
echocardiogram demonstrated mild left ventricular hypertrophy
with inferolateral hypokinesis and an ejection fraction of
40%. He was transferred to the [**Hospital6 2018**] after desaturation, recurrent pneumothorax and
subcutaneous emphysema with a persistent air leak. He has a
long history of severe chronic obstructive pulmonary disease
and radiologic studies demonstrated multiple blebs and bullae
in both lungs.
On arrival, the Cardiothoracic Surgery service placed a new
right chest tube with good effect. He continued to have a
persistent air leak and on [**6-5**], underwent video
assisted thoracoscopy with a wedge resection of a bullous
thought to be the source of his leak. The patient also
underwent pleurodesis. His postoperative course was
complicated by Serratia and Methicillin resistant
Staphylococcus aureus pneumonia for which he was placed on
antibiotics. He received ceftazidime and vancomycin directed
for his sensitivities. The patient underwent tracheostomy
and placement of a percutaneous endoscopic gastrostomy tube a
week postoperatively for failure to wean and thrive. His
mental status was quite depressed postoperatively and it took
him a long time to recover from the narcotics and sedatives
given.
At the time of discharge, he began to follow commands and
seemed to be attempting to mouth words. A PICC line was
placed on [**6-20**] for antibiotics. On [**6-23**], his chest
tube was removed. He had two CT scans during his course for
his slow mental status. They showed old basilar infarcts and
an atrophic brain. His mental status had slowly improved.
His antibiotics were completed on [**6-26**]. He is receiving
ProMod with fiber at 65 cc an hour for his goal rate tube
feedings at time of discharge. His activity is only
progressed to getting out of bed and being sat in the chair,
although he is more responsive and interactive now.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Non Hodgkin's lymphoma, low grade.
3. Bladder cancer.
4. Alcohol abuse with DTs in the past. The patient has
already not had a drink in at least six weeks.
5. Splenectomy for trauma.
6. Coronary artery disease, status post myocardial
infarction [**2194-5-24**].
7. Eighty pack year smoking history.
ALLERGIES: The patient has no known drug allergies.
DISCHARGE MEDICATIONS:
1. Olanzapine 5 mg po q day
2. Heparin 5000 units subcutaneous [**Hospital1 **]
3. Aspirin 81 mg po q day
4. Colace 100 mg po bid
5. Lopressor 25 mg po bid
6. Mupirocin cream 2% topical [**Hospital1 **] prn perirectal
7. Mupirocin nasal ointment 2% applied [**Hospital1 **] prn perinasal
8. Trazodone 25 mg po q hs prn
9. Miconazole powder applied topically tid prn
10. Bisacodyl 10 mg po q day prn
11. N-acetyl ........... 3 to 5 ml nebulized q 4 to 6 hours
prn
12. Ativan 0.5 mg po or intravenous [**Hospital1 **] prn
13. Tylenol 650 mg po q4h prn
All of his po medications are actually given his PEG tube.
PHYSICAL EXAM ON DISCHARGE:
VITAL SIGNS: Temperature 37.4??????C, heart rate 80 sinus, blood
pressure 110/70, respiratory rate 14, O2 saturations 94% on
trach mask.
NEUROLOGIC: No motor or sensory deficits. The patient is
still somewhat withdrawn, will follow commands and attempts
to mouth words occasionally and tracks well.
RESPIRATORY: The patient has coarse breath sounds
bilaterally with slight expiratory wheezes.
CARDIAC: Regular rate and rhythm, normal S1, S2. Surgical
wounds all completely healed.
ABDOMEN: Soft , nontender, nondistended, no masses, no
hernias, no ascites.
RECTAL: Guaiac negative, normal tone.
EXTREMITIES: No peripheral edema or calf tenderness,
palpable DP pulses bilaterally.
DISCHARGE LABS: White count 13,000, hematocrit 34, platelets
688. Sodium 139, potassium 4.9, chloride 102, bicarbonate
24, BUN 26, creatinine 0.6, blood sugar 120, calcium 9.4,
magnesium 2, phosphorus 3.5. His repeat sputum cultures have
been negative. A urinalysis sent the day of discharge was
nitrite positive with only 7 white blood cells. We were
awaiting urine cultures. He had not been started on
antibiotics. He had a small amount of blood in his urine.
The patient has had multiple TURPs in the past.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSES:
1. Status post myocardial infarction
2. Status post right pneumothorax
3. Status post video assisted thoracoscopy with wedge
resection and pleurodesis.
4. Chronic obstructive pulmonary disease
5. Coronary artery disease
6. Pneumonia
7. Ventilatory failure
8. Status post tracheostomy
9. Status post percutaneous endoscopic gastrostomy
DISCHARGE STATUS: The patient is being discharged to [**Hospital1 33995**] in [**Location (un) 701**], [**State 350**]. No
further follow up is required.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 11232**]
MEDQUIST36
D: [**2194-7-4**] 11:51
T: [**2194-7-4**] 12:03
JOB#: [**Job Number 42758**]
|
[
"482.41",
"410.21",
"512.1",
"998.3",
"427.1",
"202.80",
"496",
"998.81",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.92",
"43.11",
"34.6",
"33.22",
"32.29",
"38.93",
"04.81",
"34.04",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
4865, 4873
|
4894, 5674
|
2988, 3608
|
4343, 4843
|
3636, 4326
|
176, 2536
|
2558, 2965
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,532
| 163,362
|
2037
|
Discharge summary
|
report
|
Admission Date: [**2101-10-3**] Discharge Date: [**2101-10-12**]
Date of Birth: [**2019-8-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
hypotension, chills, RUQ pain
Major Surgical or Invasive Procedure:
ERCP [**10-3**]
History of Present Illness:
82M with PMH of dementia, DM2, CRI (baseline Cr 1.6), cCHF and
episode of cholangitis in [**2101-3-8**] requiring ERCP with
spincterotomy and stent placement, presented to OSH with chills
and weakness, found to be hypotensive. In [**Month (only) **], patient
presented to OSH with sharp RUQ pain, fever, found to have
cholecystitis secondary to choledocholithiasis. An ERCP was
performed, but not all the stones could be removed, so a stent
was placed to facilitate continued drainage and a sphincterotomy
was performed. During the same hospitalization, he also had a
CCY. Patient was instructed to f/u for stent removal in 1
month, but was lost to f/u. Since then, patient has had off/on
fevers over last few months, and in [**Month (only) 205**], was admitted for FUO,
thought to be due to cellulitis because they could not find
another source (but now, in retrospect, thought to be biliary).
On the day prior to transfer, patient presented to OSH with
intermittent fever, chills, weakness and RUQ pain. He had AMS
(although he has baseline dementia, so unclear how different MS
was from baseline), T101, WBC 30, elevated Tbili 1.7. CT abd
showed "stent in good place." He was found to be hypotensive to
sbp 80s, but was responsive to fluids (was given 1L NS bolus and
then 2L NS at maintenance rate), was able to maintain SBP>100.
Patient never required pressors. Due to his septic picture, he
was started empirically on Linezolid/Zosyn. Patient was
transferred to [**Hospital1 18**] in case he crashes overnight and needs
emergent ERCP in the ICU, which couldn't be done in [**Location (un) **].
Of note, patient has baseline dementia and confusion, but is not
agitated, and is oriented x self, place.
.
On transfer, his labs showed: WBC 31.8 (24% bands), hct 40.5,
plt 126.
He has been afebrile. Na 137, K3.5, Cl 101, Hco3 21, BUN 29, Cr
1.9 (baseline 1.6). Latest ABG: 7.37/39/65, satting 95%(2L).
Blood cx from [**10-1**] are pending, UA negative, CXR clear. Abd CT
with perinephric stranding (old), biliary stent in place (same
stent as placed in [**Month (only) **]) - concering for stent blocked. TB
3.0 now, ALKP 200, ALT 94. Prior to transfer, [**10-2**] blood culture
returned positive for aerobic GNR in varying sizes, GPC in
chains and pairs. An anaerobic bottle grew GNR, GPR, and rare
GPC in pairs.
.
On arrival to the ICU, patient's vitals were: T99.5 HR83
BP102/49 RR26 O2sat 99(3L). Patient is comfortable, complains
of thirst, fatigue, and headache. Very somnolent, but
conversant and responds appropriately to questions, although
does not provide many details. Denies abdominal pain,
nausea/vomiting, fevers, chills.
Past Medical History:
Diabetes, Type 2
Mild dementia
CVA
CRI (baseline Cr 1.6)
dCHF
gout
HTN
hx of cholecystitis s/p CCY
stasis dermatitis
mrsa colonization
Social History:
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No diseases that the patient can think of.
Physical Exam:
Physical Exam on Admission:
Vitals: T99.5 HR83 BP102/49 RR26 O2sat 99(3L)
General: Somnolent, oriented to self and hospital, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles, L>R
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: hypoactive BS, non-distended, tender to palpation of
RUQ and epigastrum with rebound tenderness in RUQ, no
organomegaly
Ext: warmth and erythema in LLE consistent with cellulitis, well
perfused, no edema
.
At discharge:
97.5, 119/68, 52, 20, 98 room air
-comfortable appearing
-oriented to hospital and self, conversant an pleasant, does not
know the year
-distant s1/s2
-abdomen benign with + bowel sounds
-slight crackles at lung bases
-1+ bilateral pitting edema in calves with venous stasis
changes.
Pertinent Results:
Labs on Admission:
[**2101-10-3**] 02:30AM BLOOD WBC-26.5* RBC-3.52* Hgb-10.7* Hct-32.2*
MCV-92 MCH-30.3 MCHC-33.1 RDW-14.7 Plt Ct-111*
[**2101-10-3**] 02:30AM BLOOD Neuts-78* Bands-9* Lymphs-10* Monos-2
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2101-10-3**] 02:30AM BLOOD PT-17.3* PTT-34.1 INR(PT)-1.5*
[**2101-10-3**] 02:30AM BLOOD Glucose-232* UreaN-33* Creat-1.8* Na-138
K-3.8 Cl-102 HCO3-24 AnGap-16
[**2101-10-3**] 02:30AM BLOOD ALT-48* AST-55* LD(LDH)-204 CK(CPK)-169
AlkPhos-132* Amylase-22 TotBili-2.0*
[**2101-10-3**] 02:30AM BLOOD Lipase-12
[**2101-10-3**] 02:30AM BLOOD CK-MB-3 cTropnT-0.02*
[**2101-10-3**] 02:30AM BLOOD Albumin-2.9* Calcium-7.7* Phos-2.2*
Mg-1.4*
.
ABG post-ERCP respiratory distress:
[**2101-10-3**] 02:52PM BLOOD Type-[**Last Name (un) **] Temp-38.1 Rates-/35 pO2-30*
pCO2-53* pH-7.27* calTCO2-25 Base XS--3 Intubat-NOT INTUBA
.
ERCP [**10-3**]:
Two 10 mm irregular stones that were causing partial obstruction
were seen at the distal common bile duct. The CBD measured 11
mm. 2 stones and multiple stone fragments were extracted
successfully using a balloon. Final cholangiogram revealed no
filling defects. As the bile duct was cleared completely, the
decision was made not to place an additional stent.
.
CXR [**10-3**]:
IMPRESSION:
Both lung volumes are very low. There is no conclusive evidence
to suggest
pneumonic consolidation. Apprearance of minimal vascular
congestion may be
exaggerated by very low lung volumes. No pneumothorax or pleural
effusion.
Grossly, the mediastinal, hilar, and cardiac contours appear
within a normal
limit.
.
CXR [**10-3**] respiratory distress:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Exceedingly small lung volumes. The presence of mild
pulmonary edemacannot be excluded. In the ventilated parts of
the lung parenchyma, there isno evidence of pneumonia. Bilateral
areas of basal atelectasis.
.
[**10-4**] ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Doppler parameters are
most consistent with Grade I (mild) left ventricular diastolic
dysfunction. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
.
cxr: [**10-6**]: IMPRESSION: Appropriately positioned right upper
extremity PICC.
.
MICRO; All blood cultures from [**Hospital1 18**] are negative. Copy of
original micro report from OSH showing enterococcus and ecoli
(incl senitivities) will be sent with d/c summary (attached).
PICC line culture pending at discharge.
.
Discharge labs:
[**2101-10-12**] 05:10AM BLOOD WBC-12.0* RBC-3.33* Hgb-10.1* Hct-31.0*
MCV-93 MCH-30.3 MCHC-32.6 RDW-15.0 Plt Ct-145*
[**2101-10-12**] 05:10AM BLOOD Glucose-148* UreaN-22* Creat-1.4* Na-138
K-4.3 Cl-103 HCO3-23 AnGap-16
[**2101-10-11**] 04:03AM BLOOD ALT-12 AST-15 AlkPhos-134* TotBili-0.5
[**2101-10-9**] 04:03AM BLOOD Lipase-26
[**2101-10-10**] 05:50AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0
Brief Hospital Course:
82M with prior episode of cholangitis in [**2101-3-8**] requiring
ERCP with sphincterotomy and stent placement, presented to OSH
with sepsis thought to be secondary to unremoved biliary stent.
Now s/p ERCP, stent/stone removal. Was initially bacteremic with
E. coli/Enterococcus at OSH.
.
He was admitted to the [**Hospital Unit Name 153**] initially and was septic - he met
SIRS criteria (RR>20 and WBC>12 with >10% bands) with a positive
blood culture and a likely source of infection. At OSH (prior
to transfer), patient was hypotensive but but responsive to
fluid boluses. Blood cultures from OSH [**10-2**] grew ECOLI and
enterococcus. He was initially started on linezolid and zosyn
because of a prior hx of VRE. Final culture data was received
from OSH ([**Hospital3 934**]) on [**10-11**] showing that enterococcus is
pansensitive and ecoli R only to ampicillin, bactrim, cipro. He
should terminate a two week course on [**10-16**]. Surveillance CBC and
chem 10 should be done at that time.
.
Cholangitis: Secondary to clogged billiary stent (removed) and
stones which were also removed. He had sphincterotomy done in
[**2101-3-8**]. He does not require GI follow-up but should have LFTs
done on [**10-16**] and by his PCP in one month.
.
He was in acute renal failure on arrival, Cr 1.9 elevated above
baseline 1.6. Most likely prerenal and has responded to IVF.
Renal function has continued to improve - at discharge Cr=1.4.
.
Acute on chronic diastolic heart failure: Patient had b/l
pulmonary crackles on admission to mid lung fields, consistent
with hypervolemia in the setting of diastolic heart failure and
fluid boluses given for sepsis. ECHO done here: EF>55% mild LV
diastolic dysfunction. He was effectively diuresed with IV lasix
and restarted on an oral regimen. At the ime of discharge, he
is approaching euvolemia with trace crackles at the lung bases
an minimal LE edema. His weights should be monitored daily and
his physician notified if he gains >3 lbs. Home Atenolol
initially held in the ICU for concern of sepsis - has been
restarted and tolerated well. He was reportedly on prn
hydralazine for HTN at home--this was not required in the
hospital and was discontinued.
.
Patient had area of erythema and warmth in RLE anterior
pretibial area on admission, has resolved with abx given for the
above. Some venous stasis changes persist on his lower
extremities.
.
DM2, uncontrolled with complications. Glargine was increased
from 20 qhs to 18 units [**Hospital1 **] and ISS with humlog provided. FSBS
improved on this regimen. Calorie counts showed adequate
nutrtion on a diabetic low sodium diet.
.
He was continued on allopurinol for gout. He was continued on
prilosec for GERD. He has a stable normocytic anemia and was
repeatedly guiaic negative--he should follow-up with his PCP
regarding further [**Name9 (PRE) 11156**] of this once his more acute issues
subside.
.
He has baeline dementia and developed mild delirium when
initially in the MICU. This was attributed to metabolic
encephalopathy in the setting of acute illness and largely
resolved. The night prior to discharge, he inadvertently pulled
out his PICC line.
.
Code Status: Full code during this admission.
Medications on Admission:
Lantus 20U qhs
allopurinol 100mg daily
atenolol 50mg daily
Lasix 20mg qpm adn 40mg qam
Prilosec 40mg daily
Magnesium oxide 400mg daily
Hydralazine 10mg prn [**Hospital1 **]
Ultram 25mg po q6h prn
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: One (1) PO BID (2
times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): can be weaned once patient's
mobility improves.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheeze.
8. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 4 days: to be continued until [**10-16**].
10. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q6H (every 6 hours): to be continued
until [**10-16**].
11. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
12. insulin glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous twice a day.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. med
humalog sliding scale attached
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Sepsis
Cholangitis
Acute on chronic diastolic heart failure
Acute on chronic renal failure
Toxic-metabolic encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 4042**],
You were admitted with an infection in your bloodstream due to a
stent which had been previously placed in your bile ducts. This
stent and gallstones were removed and you should continue
intravenous antibiotics for this infection for a total of 2
weeks. You also had a skin infection of the right shin area
which resolved with the IV antibiotics. You developed mild heart
failure here and your medications were adjusted. Please weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
Several of your medications have been changed. The facility to
which you are going will receive a fully updated list.
Followup Instructions:
You will be scheduled for a follow-up appointment with your
primary care doctor at the time of discharge from rehab.
You do not need to follow-up with the specialists who removed
your biliary stent.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2101-10-17**]
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6,088
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30454
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Discharge summary
|
report
|
Admission Date: [**2149-10-31**] Discharge Date: [**2149-11-7**]
Date of Birth: [**2100-12-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2149-10-31**] left mini craniotomy, rt burr holes(2) for SDH
evacuation
History of Present Illness:
This is a 48 year old male who has had prior neurosurgical
admissions for IPH/SDH. He reports that he was involved in an
altercation on Monday night, [**10-27**], and later fell while fleeing
the scene of the flight. He struck his head on his
refridgerator. A friend called 911 today when he expressed he
wasn't "feeling right". He was seen at an OSH and a CT of the
head showed bilateral acute on chronic SDH, greater on the left.
He was transferred to [**Hospital1 18**] for neurosurgical care.
Past Medical History:
s/p ICH in [**2146**] from a fall
etOH use
etOH withdrawl without seizures
Polysubstance in the past
Heavy smoker
Social History:
Former chef. Now unemployed
Tobacco: 2ppd for >30 years
etOH: Reports former heavy use. Now reports only 2 drinks / day
Illicits: Reports distant use of LSD, PCP, [**Name10 (NameIs) 57131**], and various
other substances
Family History:
Mother had TB
Father has [**Name (NI) 2481**] disease
Physical Exam:
On admission:
BP: 142/81 HR:70s R:15 O2Sats: 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3 to 2 mm Bilaterally EOMs: Intact
Neck: in hard collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
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 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 [**4-29**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
On discharge:
Alert, oriented to person, place and date. PERRL, face is
symmetric, tongue is midline. Full strength and power throughout
upper and lower extremities. Sensations is grossly intact. Wound
is clean, dry and intact without erythema, or drainage.
Pertinent Results:
[**2149-10-30**] 10:51PM PHENYTOIN-22.2*
[**2149-10-30**] 10:51PM ASA-NEG ETHANOL-70* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2149-10-30**] 10:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
[**Month/Day/Year 57131**]-NEG amphetmn-NEG mthdone-NEG
Ct Head [**2149-10-31**] OSH:
1. Large bilateral subdural hematoma with mass effect on the
cerebral
hemispheres and compression of the lateral ventricles, and 4-mm
shift of
midline structures.
2. Linear skull fracture of the left frontal bone, unchanged
compared to
prior exams.
3. Focal encephalomalacia in the anterior right frontal lobe.
Ct Head [**2149-10-31**] 1330:
1. Stable large bilateral subdural hematoma with mass effect on
the cerebral hemispheres and compression of the lateral
ventricle.
2. Nondisplaced skull fracture of the left frontal bone,
unchanged.
3. Focal encephalomalacia in the anterior right frontal lobe,
unchanged.
CT C-spine: [**2149-10-31**]
1. No acute fracture or malalignment.
2. Multilevel degenerative changes resulting in mild spinal
canal stenosis at C5-C6 and C6-C7 level.
3. Atherosclerotic vascular calcifications.
MRI C-spine [**2149-10-31**]
No evidence of cord compression. No evidence of ligamentous
injury.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] Neurosurgery under the care of
Dr. [**Last Name (STitle) **]. He was neurologically stable but had significant
sized SDH's bilaterally. He was on a CIWA scale for withdrawal
prophylaxis. He continued to receive Dilantin.
He proceded to the OR with Dr. [**Last Name (STitle) **] on [**2149-10-31**] for
decompression of SDH. He briefly required a subdural drain to
assist with the evacuation of further residual blood. This was
discontinued on POD#2. He was seen and evaluated by PT/OT and
determined appropriate for discharge, however due to his
socioeconomic situation; discharge to a sober house was
arrangement with the assistance of his family and social work.
Appropriate living situation was identified on [**2149-11-7**], and he
was discharged accordingly. He was not however discharged with
any narcotic pain medication, as the residence he was being
transferred to would not allow this.
Medications on Admission:
Dilantin
NSAIDS
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO every twelve (12) hours.
Disp:*120 Capsule(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
not to exceed more than 4gm apap in 24h.
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural Hematoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
[**Date Range 2729**] are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Name10 (NameIs) **]
Usually no special [**Name10 (NameIs) **] is prescribed after a craniotomy. A
normal well balanced [**Name10 (NameIs) **] is recommended for recovery, and you
should resume any specially prescribed [**Name10 (NameIs) **] you were eating
before your surgery.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**10-8**] days (from your date of
surgery) for removal of your staples/[**Date Range 2729**] and a wound check.
Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or
staples. Be sure to point out any incisions, which may be
covered by clothing at the time of suture/staple removal. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2149-11-7**]
|
[
"800.21",
"345.90",
"305.50",
"E888.1",
"305.1",
"E960.0",
"V43.65",
"303.91",
"V62.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.31",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
5848, 5854
|
4184, 5144
|
306, 383
|
5926, 5950
|
2930, 4161
|
10887, 11750
|
1303, 1358
|
5210, 5825
|
5875, 5905
|
5170, 5187
|
5974, 9029
|
1373, 1373
|
2666, 2911
|
9056, 10864
|
262, 268
|
411, 911
|
1904, 2652
|
1387, 1651
|
1666, 1888
|
933, 1048
|
1064, 1287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,335
| 185,495
|
46945+58961
|
Discharge summary
|
report+addendum
|
Admission Date: [**2156-6-12**] Discharge Date: [**2156-6-27**]
Date of Birth: [**2094-1-24**] Sex: M
Service: NEUROLOGY
Allergies:
Pentasa / Mercaptopurine / Penicillins
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Change in mental status, right sided weakness
Major Surgical or Invasive Procedure:
[**2156-6-12**]
Left ICA stenting, followed by IA t-PA, and clot
retrieval using the Merci & Penumbra devices.
History of Present Illness:
Mr [**Known lastname **] is a 62 yo male with a history of hypertension,
ulcerative colitis, and mild depression who presents with
decreased responsiveness and R hemiparesis consistent with L MCA
stroke. The patient was last seen normal at 9:30 am on the day
of
admission. He was found by his wife at 10:30 am on the day of
admission, on the floor laying on his side and incontinent of
urine. His wife reported that he was nonverbal, but it was
unclear if there was any focal weakness at this time. Per his
wife, 1 week prior to admission he had an episode of left sided
blurry vision.
.
EMS was called and took him to [**Hospital6 33**] ED, and was
intubated for altered mental status and given Lidocaine 50,
Etomidate 20, Succs 80, Versed 2, Vecuronium 5 IV x2, and Ativan
1 gm IV x1. Neuro exam at the OSH (11:20 am) showed the patient
was intubated, squeezed left hand to command, R CN VII paresis,
motor [**4-5**] of left arm and leg, [**2-4**] R leg at the thigh but cannot
elevate the right heel off the bed. 0/5 R arm movement. Planter
reflex was down. CT Head at OSH showed hyperdensity involving
the
left MCA, no evidence of ICH, and subtle hypodensity involving
the left cerebral hemisphere consistent with infarction.
Incidental note was also made of an 8 mm hyperdense focus
anterior to the sella which is suspicious for an aneurysm of the
anterior communicating artery. It was determined that he was not
an IV tPA candidate because of likely seizure at the onset, and
he was transferred to [**Hospital1 18**].
.
Patient arrived to the [**Hospital1 18**] ED and CODE STROKE was called at
1:57pm. Neurology was at the bedside within 5 minutes. NIHSS was
21 - for LOC, motor arm and leg, aphasia. Examination was
limited
by medications and intubation. CT Head showed occlusion of left
carotid and left MCA at origin, and hypodensity of left cerebral
hemisphere. CT Perfusion showed decreased blood volume and
increased mean transit time, with mismatch between the images.
The family was contact[**Name (NI) **] and consented, and the patient was
taken
to the angiography lab for IA tPA and Merci cath/Penumbra.
Past Medical History:
-Hypertension
-Ulcerative Colitis
-Mild Depression, Prozac discontinued on [**2156-2-12**]
-Erectile Dysfuncion
-GERD
-Bilateral trigger fingers s/p release of trigger finger right
long and ring digits, excision of retinacular cyst right index
finger, and trigger release right index finger [**2156-4-29**]
Social History:
Social History (per records): He is married. He does not smoke
cigarettes and rarely drinks alcohol. The patient has had
recent stressors in his life including some health problems of
his wife and his son recently being diagnosed with chronic
pancreatitis due to alcohol abuse.
Family History:
Family History (per records): Positive for emphysema, dementia,
and CVA. Negative for inflammatory bowel disease or colon
cancer.
Physical Exam:
NIHSS:
1a. LOC: 2 - arousable only to painful stimulation
1b. LOC Questions: 1 - intubated
1c. Commands: 1 - intubated
2. Best Gaze: 2 - forced eye deviation
3. Visual Field: 9 - cannot perform (do not score)
4. Facial Palsy: 0 - Normal
5. Motor Arm: 4 on right (no movement), 2 on left (some
antigravity effort but can't sustain)
6. Motor Leg: 4 on right (no movement), 2 on left (some
antigravity effort but can't sustain)
7. Limb Ataxia: X - unable to assess
8. Sensory: 0 - Normal
9. Best Language: 3 - aphasia
10. Dysarthria: X - intubation
11. Extinction/Neglect - X
-------
Total: 21
.
Vitals: bp 142/78, HR 83, RR 11
Genl: Intubated, does not open eyes to command.
Neuro: The patient is intubated and sedated, so much of the exam
was deferred. No withdrawal to nasal tickle. Left arm and leg
withdraw to nailbed pressure, right arm and does not move to
noxious stimulus. Right leg shows triple flexion to noxious
stimulus. Eyes deviated to the left bilaterally. Plantar
relflexes extensor bilaterally.
Pertinent Results:
[**2156-6-25**] 07:10AM BLOOD WBC-6.2 RBC-3.13* Hgb-9.3* Hct-27.4*
MCV-88 MCH-29.6 MCHC-33.8 RDW-13.5 Plt Ct-224
[**2156-6-24**] 01:57AM BLOOD WBC-8.8 RBC-3.43* Hgb-10.0* Hct-29.4*
MCV-86 MCH-29.1 MCHC-33.9 RDW-13.6 Plt Ct-257
[**2156-6-23**] 03:30AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.8* Hct-28.5*
MCV-88 MCH-30.3 MCHC-34.4 RDW-13.5 Plt Ct-266
[**2156-6-22**] 02:06AM BLOOD WBC-9.0 RBC-3.38* Hgb-10.0* Hct-30.1*
MCV-89 MCH-29.7 MCHC-33.3 RDW-13.6 Plt Ct-253
[**2156-6-21**] 02:23AM BLOOD WBC-8.7 RBC-3.46* Hgb-10.3* Hct-31.0*
MCV-90 MCH-29.9 MCHC-33.4 RDW-13.8 Plt Ct-276
[**2156-6-20**] 08:17PM BLOOD Hct-32.6*
[**2156-6-20**] 03:07AM BLOOD WBC-9.9 RBC-3.78* Hgb-11.1* Hct-33.7*
MCV-89 MCH-29.3 MCHC-32.8 RDW-13.9 Plt Ct-267
[**2156-6-19**] 02:00AM BLOOD WBC-8.6 RBC-3.62* Hgb-10.6* Hct-33.3*
MCV-92 MCH-29.2 MCHC-31.7 RDW-13.7 Plt Ct-218
[**2156-6-18**] 01:30AM BLOOD WBC-7.7 RBC-3.13* Hgb-9.8* Hct-28.5*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.8 Plt Ct-206
[**2156-6-17**] 02:00AM BLOOD WBC-7.5 RBC-3.15* Hgb-9.5* Hct-29.1*
MCV-92 MCH-30.2 MCHC-32.7 RDW-13.9 Plt Ct-184
[**2156-6-16**] 02:54AM BLOOD WBC-9.7 RBC-3.20* Hgb-9.9* Hct-29.3*
MCV-91 MCH-31.0 MCHC-34.0 RDW-14.1 Plt Ct-163
[**2156-6-15**] 02:07AM BLOOD WBC-11.9* RBC-3.52* Hgb-10.3* Hct-31.4*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.2 Plt Ct-151
[**2156-6-14**] 02:43AM BLOOD WBC-12.4* RBC-3.52* Hgb-10.5* Hct-31.2*
MCV-89 MCH-29.8 MCHC-33.7 RDW-14.3 Plt Ct-151
[**2156-6-13**] 09:27PM BLOOD Hct-30.4*
[**2156-6-13**] 11:10AM BLOOD Hct-32.6*
[**2156-6-13**] 04:32AM BLOOD WBC-11.5* RBC-3.86* Hgb-11.6* Hct-34.6*
MCV-90 MCH-30.0 MCHC-33.5 RDW-14.1 Plt Ct-175
[**2156-6-12**] 07:31PM BLOOD WBC-12.0* RBC-3.94* Hgb-11.7* Hct-35.6*
MCV-90 MCH-29.7 MCHC-33.0 RDW-14.2 Plt Ct-209
[**2156-6-12**] 02:08PM BLOOD WBC-10.7 RBC-4.07* Hgb-12.0* Hct-36.6*
MCV-90 MCH-29.5 MCHC-32.8 RDW-14.1 Plt Ct-159
[**2156-6-12**] 02:08PM BLOOD Neuts-91.6* Bands-0 Lymphs-6.0* Monos-2.2
Eos-0.1 Baso-0.2
[**2156-6-12**] 02:08PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Tear Dr[**Last Name (STitle) **]1+
[**2156-6-25**] 12:55PM BLOOD PT-14.4* PTT-26.7 INR(PT)-1.2*
[**2156-6-25**] 07:10AM BLOOD Plt Ct-224
[**2156-6-25**] 07:10AM BLOOD PT-17.2* PTT-27.1 INR(PT)-1.6*
[**2156-6-24**] 01:57AM BLOOD Plt Ct-257
[**2156-6-23**] 03:30AM BLOOD Plt Ct-266
[**2156-6-22**] 02:06AM BLOOD Plt Ct-253
[**2156-6-21**] 02:23AM BLOOD Plt Ct-276
[**2156-6-20**] 03:07AM BLOOD Plt Ct-267
[**2156-6-19**] 02:00AM BLOOD Plt Ct-218
[**2156-6-18**] 01:30AM BLOOD Plt Ct-206
[**2156-6-17**] 02:00AM BLOOD Plt Ct-184
[**2156-6-17**] 02:00AM BLOOD PT-13.2 PTT-24.7 INR(PT)-1.1
[**2156-6-16**] 02:54AM BLOOD Plt Ct-163
[**2156-6-15**] 02:07AM BLOOD Plt Ct-151
[**2156-6-14**] 02:43AM BLOOD Plt Ct-151
[**2156-6-13**] 04:32AM BLOOD Plt Ct-175
[**2156-6-13**] 04:32AM BLOOD PT-14.6* PTT-26.9 INR(PT)-1.3*
[**2156-6-12**] 07:31PM BLOOD Plt Ct-209
[**2156-6-12**] 07:31PM BLOOD PT-13.8* PTT-28.6 INR(PT)-1.2*
[**2156-6-12**] 02:08PM BLOOD PT-14.5* PTT-27.8 INR(PT)-1.3*
[**2156-6-12**] 02:08PM BLOOD Plt Smr-LOW Plt Ct-159
[**2156-6-25**] 07:10AM BLOOD Glucose-115* UreaN-19 Creat-0.7 Na-138
K-4.0 Cl-106 HCO3-24 AnGap-12
[**2156-6-24**] 01:57AM BLOOD Glucose-117* UreaN-19 Creat-0.8 Na-136
K-4.2 Cl-103 HCO3-24 AnGap-13
[**2156-6-23**] 03:30AM BLOOD Glucose-115* UreaN-23* Creat-0.7 Na-137
K-3.7 Cl-101 HCO3-25 AnGap-15
[**2156-6-22**] 02:06AM BLOOD Glucose-115* UreaN-33* Creat-0.8 Na-137
K-3.7 Cl-105 HCO3-24 AnGap-12
[**2156-6-21**] 02:23AM BLOOD Glucose-146* UreaN-30* Creat-0.8 Na-138
K-3.6 Cl-106 HCO3-21* AnGap-15
[**2156-6-20**] 07:16PM BLOOD K-3.8
[**2156-6-20**] 03:07AM BLOOD Glucose-147* UreaN-25* Creat-0.9 Na-137
K-3.6 Cl-107 HCO3-21* AnGap-13
[**2156-6-19**] 02:00AM BLOOD Glucose-112* UreaN-16 Creat-0.8 Na-139
K-3.9 Cl-107 HCO3-22 AnGap-14
[**2156-6-18**] 02:37PM BLOOD Na-141 K-3.7
[**2156-6-18**] 01:30AM BLOOD Glucose-113* UreaN-18 Creat-0.7 Na-140
K-4.2 Cl-105 HCO3-26 AnGap-13
[**2156-6-17**] 07:31PM BLOOD Na-141
[**2156-6-17**] 12:11PM BLOOD Na-141 K-4.3
[**2156-6-17**] 02:00AM BLOOD Glucose-113* UreaN-24* Creat-0.8 Na-141
K-3.9 Cl-106 HCO3-28 AnGap-11
[**2156-6-16**] 08:02PM BLOOD Na-142
[**2156-6-16**] 02:54AM BLOOD Glucose-123* UreaN-20 Creat-0.8 Na-140
K-4.3 Cl-107 HCO3-26 AnGap-11
[**2156-6-15**] 09:43PM BLOOD K-3.7
[**2156-6-15**] 01:40PM BLOOD Glucose-123* UreaN-15 Creat-0.8 Na-140
K-3.6 Cl-105 HCO3-27 AnGap-12
[**2156-6-15**] 02:07AM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-106 HCO3-25 AnGap-11
[**2156-6-14**] 01:30PM BLOOD Na-138 K-4.1 Cl-106
[**2156-6-14**] 02:43AM BLOOD Glucose-125* UreaN-11 Creat-0.8 Na-135
K-4.0 Cl-104 HCO3-23 AnGap-12
[**2156-6-13**] 09:27PM BLOOD K-3.8
[**2156-6-13**] 03:39PM BLOOD K-3.3
[**2156-6-13**] 04:32AM BLOOD Glucose-124* UreaN-12 Creat-0.9 Na-134
K-4.2 Cl-103 HCO3-23 AnGap-12
[**2156-6-12**] 07:31PM BLOOD Glucose-96 UreaN-10 Creat-0.8 Na-135
K-4.0 Cl-103 HCO3-24 AnGap-12
[**2156-6-12**] 02:08PM BLOOD Glucose-120* UreaN-12 Creat-1.0 Na-138
K-3.6 Cl-103 HCO3-26 AnGap-13
[**2156-6-13**] 04:32AM BLOOD CK(CPK)-294*
[**2156-6-12**] 02:08PM BLOOD ALT-31 AST-26 CK(CPK)-197* AlkPhos-63
TotBili-0.5
[**2156-6-13**] 04:32AM BLOOD CK-MB-3 cTropnT-<0.01
[**2156-6-12**] 02:08PM BLOOD CK-MB-4
[**2156-6-12**] 02:08PM BLOOD cTropnT-<0.01
[**2156-6-25**] 12:55PM BLOOD Albumin-3.0*
[**2156-6-25**] 07:10AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.3
[**2156-6-24**] 01:57AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2
[**2156-6-22**] 02:06AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1
[**2156-6-21**] 02:23AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
[**2156-6-20**] 07:16PM BLOOD Mg-2.0
[**2156-6-20**] 03:07AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1
[**2156-6-19**] 02:00AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.2
[**2156-6-18**] 02:37PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.0
[**2156-6-18**] 01:30AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0
[**2156-6-17**] 12:11PM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2
[**2156-6-17**] 02:00AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.1
[**2156-6-16**] 02:54AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.2
[**2156-6-15**] 09:43PM BLOOD Calcium-8.6 Mg-2.2
[**2156-6-15**] 08:29AM BLOOD Cholest-127
[**2156-6-15**] 02:07AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1
[**2156-6-14**] 01:30PM BLOOD Calcium-7.9* Phos-2.3* Mg-2.1
[**2156-6-14**] 02:43AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.0
[**2156-6-13**] 09:27PM BLOOD Calcium-8.0* Mg-2.0
[**2156-6-13**] 03:39PM BLOOD Calcium-7.5* Phos-2.5* Mg-1.9
[**2156-6-13**] 04:32AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.7 Cholest-124
[**2156-6-12**] 07:31PM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
[**2156-6-12**] 02:08PM BLOOD Albumin-4.0 Calcium-8.1* Phos-3.1 Mg-1.7
[**2156-6-15**] 08:29AM BLOOD %HbA1c-4.5*
[**2156-6-13**] 04:32AM BLOOD %HbA1c-5.0
[**2156-6-13**] 04:32AM BLOOD Triglyc-71 HDL-30 CHOL/HD-4.1 LDLcalc-80
[**2156-6-20**] 07:16PM BLOOD Osmolal-292
[**2156-6-20**] 12:01PM BLOOD Osmolal-290
[**2156-6-20**] 03:07AM BLOOD Osmolal-290
[**2156-6-19**] 09:17PM BLOOD Osmolal-288
[**2156-6-19**] 09:50AM BLOOD Osmolal-289
[**2156-6-19**] 02:00AM BLOOD Osmolal-289
[**2156-6-18**] 02:37PM BLOOD Osmolal-289
[**2156-6-18**] 01:30AM BLOOD Osmolal-289
[**2156-6-17**] 07:31PM BLOOD Osmolal-291
[**2156-6-17**] 12:11PM BLOOD Osmolal-291
[**2156-6-17**] 02:00AM BLOOD Osmolal-295
[**2156-6-16**] 08:02PM BLOOD Osmolal-297
[**2156-6-16**] 02:54AM BLOOD Osmolal-293
[**2156-6-15**] 09:43PM BLOOD Osmolal-297
[**2156-6-15**] 01:40PM BLOOD Osmolal-287
[**2156-6-15**] 07:30AM BLOOD Osmolal-286
[**2156-6-15**] 02:07AM BLOOD Osmolal-289
[**2156-6-14**] 07:55PM BLOOD Osmolal-286
[**2156-6-14**] 01:30PM BLOOD Osmolal-282
[**2156-6-14**] 02:43AM BLOOD Osmolal-277
[**2156-6-13**] 09:27PM BLOOD Osmolal-275
[**2156-6-21**] 05:41AM BLOOD Vanco-14.5
[**2156-6-18**] 08:21AM BLOOD Vanco-6.3*
[**2156-6-12**] 02:08PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2156-6-19**] 02:06AM BLOOD Type-ART pO2-134* pCO2-38 pH-7.44
calTCO2-27 Base XS-2
[**2156-6-18**] 02:53PM BLOOD Type-ART pO2-73* pCO2-37 pH-7.50*
calTCO2-30 Base XS-4
[**2156-6-18**] 01:49AM BLOOD Type-ART pO2-202* pCO2-37 pH-7.47*
calTCO2-28 Base XS-4
[**2156-6-18**] 12:40AM BLOOD Type-ART pO2-68* pCO2-35 pH-7.47*
calTCO2-26 Base XS-1
[**2156-6-17**] 12:22PM BLOOD Type-ART pO2-135* pCO2-37 pH-7.47*
calTCO2-28 Base XS-4
[**2156-6-17**] 02:38AM BLOOD Type-ART pO2-131* pCO2-39 pH-7.45
calTCO2-28 Base XS-3
[**2156-6-16**] 03:13AM BLOOD Type-ART pO2-153* pCO2-41 pH-7.47*
calTCO2-31* Base XS-6
[**2156-6-14**] 01:41PM BLOOD Type-ART pO2-150* pCO2-37 pH-7.47*
calTCO2-28 Base XS-4
[**2156-6-14**] 02:57AM BLOOD Type-ART pO2-125* pCO2-36 pH-7.46*
calTCO2-26 Base XS-2
[**2156-6-13**] 11:22AM BLOOD Type-ART pO2-132* pCO2-31* pH-7.47*
calTCO2-23 Base XS-0
[**2156-6-12**] 07:46PM BLOOD Type-ART pO2-202* pCO2-42 pH-7.38
calTCO2-26 Base XS-0
[**2156-6-12**] 03:36PM BLOOD Type-ART pO2-363* pCO2-44 pH-7.37
calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2156-6-18**] 02:53PM BLOOD Glucose-107*
[**2156-6-17**] 02:38AM BLOOD Glucose-104 Lactate-0.8
[**2156-6-14**] 01:41PM BLOOD Glucose-103
[**2156-6-14**] 02:57AM BLOOD K-3.9
[**2156-6-12**] 03:36PM BLOOD Glucose-91 Lactate-1.3 Na-134* K-4.0
Cl-100
[**2156-6-12**] 03:36PM BLOOD Hgb-11.8* calcHCT-35
[**2156-6-18**] 02:53PM BLOOD freeCa-1.14
[**2156-6-17**] 12:22PM BLOOD freeCa-0.97*
[**2156-6-17**] 02:38AM BLOOD freeCa-1.06*
[**2156-6-16**] 03:13AM BLOOD freeCa-1.11*
[**2156-6-14**] 01:41PM BLOOD freeCa-1.11*
[**2156-6-14**] 02:57AM BLOOD freeCa-1.13
[**2156-6-12**] 07:46PM BLOOD freeCa-1.14
[**2156-6-12**] 03:36PM BLOOD freeCa-1.02*
Brief Hospital Course:
Course in the ICU:
Admitted to ICU on [**2156-6-12**]
[**2156-6-15**] - Staph coag +, treated with Vanc (did receive a couple
of doses of Zosyn)
[**2156-6-17**] Open tracheostomy and percutaneous endoscopic
gastrostomy.
Surgeon: [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]
For Failure to wean, poor nutritional status.
[**2156-6-24**] Transferred out of the ICU to the stroke floor. Physical
and neurological exam remains unchanged. Pt able to follow some
motor commands (both midline and appendicular). No verbal
responses. Flaccid right UE and LE plegia. Blinks to threat on
L. Some R neglect.
[**2156-6-26**] Bed available at [**Hospital **] Hospital for acute rehab and
pt transferred.
Medications on Admission:
Lisinopril-HCTZ 20 mg-25 mg, 1 tablet PO qAM
Omeprazole 20 mg PO daily
Sildenafil 50 mg PO prn
Sulfasalazine 1500 mg PO qid
Folic Acid 1 mg PO daily
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-3**]
Drops Ophthalmic PRN (as needed).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day) as needed.
8. Acetaminophen 160 mg/5 mL Solution Sig: Five (5) mL PO Q6H
(every 6 hours) as needed for temp>100.4.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed.
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
14. Memantine 5 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
L-MCA territory infarction
Discharge Condition:
stable
Discharge Instructions:
You have had a major stroke on the left side of your brain,
affecting your language and right sided motor strength. In order
to prevent future stroke, it is important to modify your risk
factors including keeping your blood pressure and blood lipids
under control (including continuing to take Lipitor) as well as
continuing to take Plavix, which functions to prevent platelets
from sticking together, and will prevent your carotid stent from
re-occluding. Please return to the ER if you expereince any
sudden weakness, headaches, vertigo, changes in vision,
senstion, or communication/non-verbal speech.
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1694**]. Provider: [**Name10 (NameIs) 1730**] [**Name8 (MD) 99568**], M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2156-10-25**] 11:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2156-6-25**] Name: [**Known lastname 6779**] JR,[**Known firstname **] J Unit No: [**Numeric Identifier 15951**]
Admission Date: [**2156-6-12**] Discharge Date: [**2156-6-27**]
Date of Birth: [**2094-1-24**] Sex: M
Service: NEUROLOGY
Allergies:
Pentasa / Mercaptopurine / Penicillins
Attending:[**First Name3 (LF) 3326**]
Addendum:
Mr. [**Known lastname **] had one black stool that was guaiac positive on
[**6-26**]. Several hematocrit measurements were stable over the
course of the day. He had another stool that on visual
inspection and guaiac examination was negative for blood. He was
felt to be appropriate for discharge.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 3327**]
Completed by:[**2156-6-27**]
|
[
"530.81",
"518.81",
"482.49",
"433.11",
"342.01",
"792.1",
"311",
"556.9",
"781.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"96.6",
"99.10",
"43.11",
"31.1",
"88.41",
"96.72",
"33.22",
"00.45",
"00.40",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
18008, 18215
|
13944, 14699
|
346, 458
|
16299, 16308
|
4439, 13921
|
16961, 17985
|
3252, 3385
|
14899, 16135
|
16249, 16278
|
14725, 14876
|
16332, 16938
|
3400, 4420
|
261, 308
|
486, 2610
|
2632, 2941
|
2957, 3236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,301
| 150,908
|
1615
|
Discharge summary
|
report
|
Admission Date: [**2111-5-9**] Discharge Date: [**2111-5-25**]
Date of Birth: [**2062-7-15**] Sex: F
Service: MEDICINE
Allergies:
Zithromax
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Lumbar puncture x 2
PICC line placement
History of Present Illness:
48 year old female with h/o mitral prolapse/mitral regurgitation
who presents with chief complaint of pneumonia, diarrhea, and
new visual changes and decreased hearing s/p starting Z-pack on
Wednesday. She initially was seen in the ER 3 days prior to
admission and was diagnosed with pneumonia. XRay showed hazy
opacity in the left lower lobe. She was started on a z-pack,
however did not tolerate it well and developed blurry vision and
decreased hearing b/l. +Associated nausea. In addition patient
reports worsening breathing over the last 3 days as well, with
increased dyspnea on exertion, and non-productive cough. No
associated fever, chills.
No chest pain.
In ER, O2 sat 77% RA, RR 22-> 5L nasal cannula 96-97%. CXR w/
evidence of pulmonary edema concerning for congestive heart
failure, acute, systolic. CTA negative for PE or pericardial
effusion. Fever in ER to 102, blood cultures pending. given
levofloxacin for presumed community-acquired pneumonia.
ROS: as per HPI. in addition, + anxiety ,+ decreased PO intake.
no brbpr or melanotic stools. no dysuria. no LH,dizziness,
palpitations. otherwise negative
Past Medical History:
-mitral prolapse w/ mitral regurgitation- mod/severe on ECHO
[**2108**], EF 60%
Social History:
Lives with 4 yo adopted daughter. [**Name (NI) 1403**] for a
hospice. Has a dog. [**Last Name 9361**] problem at home, with both animals
and waste seen. no sexual activity x 2 years. Lives in
[**Location 2312**].
EtOH: {}N {X}Y Amount: social
Tobacco: {X}N {}Y Amount:
Drugs: {X}N {}Y Amount:
Married: {X}N {}Y Divorced {} SO {}
Occupations: hospice
Exposures: dog, mice
Travel: [**Country 9362**] approx 4 years ago; [**State 4565**] last year but no
camping or hiking
Pets: dog
Family History:
father: colon cancer age 50
Physical Exam:
99.3, 115/65, HR 104-114, RR 42, O2 94-96% 3L NC
gen- sitting up in bed, tachypneic, fatigued appearing
heent- EOMI. OP clear. vision 20/70 equal b/l per neuro note,
subjectively more blurry in L eye
neck- 10-12 cm prominent JVD
Pulm- dense rales [**1-21**] way up lung b/l, labored breaths
cv- tachy, nl s1/s2, no murmur appreciated
abd- soft, NT/ND. NABS
ext- no edema, warm, 2+ pulses
skin- no rash
neuro- oriented x 3. language appropriate. motor strength full.
decreased hearing b/l to finger rub, symmetric.
Affect- normal
Pertinent Results:
admission labs:
------------
[**2111-5-9**] 05:40PM WBC-6.1# RBC-4.37 HGB-12.7 HCT-35.8* MCV-82
MCH-29.1 MCHC-35.5* RDW-13.5
[**2111-5-9**] 05:40PM NEUTS-80.9* BANDS-0 LYMPHS-14.5* MONOS-3.8
EOS-0.3 BASOS-0.4
[**2111-5-9**] 05:40PM PLT SMR-LOW PLT COUNT-115*
[**2111-5-9**] 05:40PM GLUCOSE-118* UREA N-11 CREAT-0.9 SODIUM-131*
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-28 ANION GAP-14
[**2111-5-9**] 08:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2111-5-9**] 08:20PM URINE RBC-0-2 WBC-[**3-25**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2111-5-9**] 08:20PM LACTATE-0.9
Reports:
--------
[**2111-5-9**]- head Ct- NON-CONTRAST HEAD CT: There is no acute
intracranial hemorrhage or major vascular territorial infarct.
[**Doctor Last Name **]-white matter differentiation is preserved. The ventricles
are normal in size and configuration. The visualized paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: Normal head CT.
[**2111-5-9**]- PA AND LATERAL RADIOGRAPHS OF THE CHEST: There has been
marked interval development of CHF compared to two days prior,
with moderate interstitial edema, cephalization of vasculature,
Kerley B lines, and small bilateral pleural effusions with
associated atelectasis. There is no focal consolidation. The
heart is also mildly enlarged. The osseous structures are
unremarkable.
IMPRESSION: Interval development of moderate CHF and small
bilateral pleural effusions. No focal consolidation.
[**2111-5-9**]- CTA chest-
CTA OF THE CHEST: There is no evidence of pulmonary embolism
within the main right and left pulmonary arteries as well as the
lobar branches. The subsegmental branches are difficult to
evaluate due to respiratory motion, however, no PE is readily
apparent. There is no aortic dissection. The heart is moderately
enlarged. There is no pericardial effusion. Small bilateral
pleural effusions are seen, with associated atelectasis. There
is moderate CHF as evidenced by diffuse septal thickening,
cephalization of the vasculature, and the small pleural
effusions. In addition, there are small scattered peripheral
areas of nodularity, tree-in-[**Male First Name (un) 239**] opacity, and ground-
glass which are likely due to atelectasis and alveolar edema
related to the patient's CHF. Mediastinal lymphadenopathy is
prominent including a conglomerate area of lymph nodes in the
prevascular space measuring 5.9 x 1.3 cm, subcarinal lymph node
conglomerate measuring 4.4 x 2 cm, right hilar lymph node
measuring 0.8 cm. There are no pathologically enlarged axillary
lymph nodes. The visualized portion of the upper abdomen is
unremarkable.
There are no suspicious lytic or sclerotic lesions.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Moderate CHF with cardiomegaly, extensive interstitial edema,
and small bilateral pleural effusions with associated
atelectasis.
3. Prominent mediastinal lymphadenopathy, which may be reactive
to the pulmonary process, however, also raises the possibility
(in conjunction with the finding of CHF in this young patient)
of an underlying connective tissue disorder such as lupus.
[**2111-5-9**]: EKG nsr, TWI v1, v3. similar to previous
[**Telephone/Fax (1) 9363**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 9364**],[**Known firstname **] A [**2062-7-15**] 48 Female [**Numeric Identifier 9365**]
[**Numeric Identifier 9366**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]
SPECIMEN SUBMITTED: CSF for immunophenotyping
Procedure date Tissue received Report Date Diagnosed
by
[**2111-5-15**] [**2111-5-15**] [**2111-5-20**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/tk??????
Previous biopsies: [**-7/4946**] SKIN LEFT LATERAL SHIN (1 JAR).
[**-6/3785**] RECTAL POLYP (1).
[**-3/2253**] LT ARM.
[**-1/2649**] RT BREAST EXC/st/bb.
(and more)
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens 3, 4, 5, 8, 10, 16, 19, 20, 45, 56.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. Lymphocytes and monocytes comprise
approximately 55% of total analyzed events. B cells comprise
approximately 7% of lymphoid-gated events and do not express
aberrant antigens. T cells comprise approximately 77% of
lymphoid gated events, expressed mature lineage antigens, and
have a helper-cytotoxic ratio of 1.0 (usual range in blood
0.7-3.0).
Natural killer cells account for approximately 14% of lymphoid
gated events.
INTERPRETATION.
Non-specific T-cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by B-cell lymphoma are
not seen in specimen. Correlation with clinical findings and
morphology is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts of sample preparation.
Note: This test was performed using analyte specific reagents
(ASRs). These ASRs have not been cleared or approved by the US
Food and Drug Administration (FDA). However, the FDA has
determined that such clearance or approval is not necessary .
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at [**Hospital1 771**], which is licensed by CLIA to perform
high complexity tests. This test was used for clinical
purposes; it should not be regarded as for research.
[**Known lastname **], [**Known firstname **] A. [**Hospital1 18**] [**Numeric Identifier 9367**]Portable
TTE (Complete) Done [**2111-5-12**] at 9:29:26 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) 3688**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **], Critical Care & [**Last Name (un) 9368**]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 830**], [**Hospital Ward Name 23**] 8
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2062-7-15**]
Age (years): 48 F Hgt (in): 64
BP (mm Hg): 102/59 Wgt (lb): 143
HR (bpm): 125 BSA (m2): 1.70 m2
Indication: Left ventricular function. Mitral valve disease.
Mitral valve prolapse. Bubble study.
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2111-5-12**] at 09:29 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: East Echo
Lab
Contrast: Saline Tech Quality: Adequate
Tape #: 2008E022-0:13 Machine: Vivid [**7-21**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 2.6 cm <= 4.0 cm
Right Atrium - Four Chamber Length: 3.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: *0.28 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 10
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 211 ms 140-250 ms
TR Gradient (+ RA = PASP): 23 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2108-12-28**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO
by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
regional LV systolic function. False LV tendon (normal variant).
Low normal LVEF. [Intrinsic LV systolic function likely
depressed given the severity of valvular regurgitation.] No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. No 2D or
Doppler evidence of distal arch coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Moderate/severe MVP. Moderate (2+) MR. LV inflow uninterpretable
due to tachycardia and/or fusion of spectral Doppler E and A
waves
TRICUSPID VALVE: Tricuspid valve not well visualized.
Physiologic TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm).
Conclusions
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is passage of a few late bubbles, which
may consistent with pulmonary arteriovenous malformations. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation.The mitral valve
leaflets are mildly thickened. There is moderate anterior >
posterior mitral valve prolapse. The severity of regurgitation
is difficult to assess due to tachycardia but appears moderate
(2+) in severity. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Resting tachycardia. No ASD by 2D/color Doppler
evaluation, but visualization of a few late bubbles (after 10
beats) which may be consistent with pulmonary AVMs. Borderline
normal left ventricular systolic function. Moderate mitral valve
prolapse. Moderate mitral regurgitation (difficult to assess
severity due to marked tachycardia).
Compared to the prior study of [**2108-12-28**], the heart rate is
significantly faster. Overall left ventricular function appear
less vigorous.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2111-5-12**] 11:18
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2111-5-13**] 8:18 AM
MR HEAD W & W/O CONTRAST
Reason: eval for mass lesion or meningeal enhancement
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with transaminitis, hypoxia, tachypnea, new
onset hearing loss, and now 1 episode of possible seizure
REASON FOR THIS EXAMINATION:
eval for mass lesion or meningeal enhancement
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with possible seizures, hypoxia,
tachypnea, and transaminitis. For further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images obtained before gadolinium. T1 sagittal,
axial, and coronal images obtained following gadolinium.
FINDINGS: There is increased signal identified along the
ependymal margins of both temporal horns and atrial regions of
both lateral ventricles. In addition, increased signal is seen
in the fourth ventricle along the ependymal margins extending to
both bilateral foramen Luschka and inferiorly to foramen
Magendie. Following gadolinium, enhancement is identified in
these regions along the ependymal margins. Additionally, there
is subtle increased signal and enhancement seen in both internal
auditory canals and along the superior aspect of the pituitary
gland, indicating meningeal enhancement along the basal
cisterns. There is no focal parenchymal abnormalities seen.
There is no slow diffusion identified. There is no hydrocephalus
or midline shift seen.
IMPRESSION: Findings indicative of ependymal and subependymal
increased signal with enhancement in atria and temporal horns of
both lateral ventricles as well as in the fourth ventricle.
Enhancement in the internal auditory canals and mild enhancement
along the basal cisterns. This finding is non-specific and could
be secondary to leptomeningeal processes such as lymphoma,
sarcoid, or Lyme disease. Alternatively metastatic disease can
have a similar appearance. Clinical correlation with CSF
findings recommended for further assessment.
Cytology Report SPINAL FLUID Procedure Date of [**2111-5-15**]
REPORT APPROVED DATE: [**2111-5-19**]
SPECIMEN RECEIVED: [**2111-5-15**] 08-[**Numeric Identifier 9369**] SPINAL FLUID
SPECIMEN DESCRIPTION: Received specimen in Cytolyt.
Prepared one ThinPrep slide.
CLINICAL DATA: Patient with hypoxia, LFT abnormalities,
mediastinal LAD, MS changes with abnormal
brain MRI.
PREVIOUS BIOPSIES:
[**2109-12-13**] [**-6/4627**] PAP
[**2108-12-7**] [**-5/4500**] THIN LAYER PREP PAP SMEAR
[**2099-7-9**] 96-[**Numeric Identifier 9370**] PAP
[**2099-5-7**] 96-[**Numeric Identifier 9371**] PAP
95-[**Numeric Identifier 9372**] PAP
95-[**Numeric Identifier 9373**] PAP
REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **]
DIAGNOSIS: Cerebrospinal fluid:
Predominantly small lymphocytes with occasional large forms.
Flow cytometric studies revealed predominantly T-cells
with admixed polyclonal B cells (see S08-[**Numeric Identifier **]).
A reactive process is favored.
Note:
Hematopathology consult performed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2111-5-14**] 1:57 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: ? additional abd/pelvic LAD
[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with mediastinal LAD, leptomeningeal
enhancement with abnl CSF, hypoxia, abnormal LFTs, fever,
thrombocytopenia.
REASON FOR THIS EXAMINATION:
? additional abd/pelvic LAD
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 48-year-old woman with mediastinal lymphadenopathy
and leptomeningeal enhancement and abnormal liver function
tests. Please evaluate for abdominal lymphadenopathy.
Comparison is made to the prior CT of the chest of [**2111-5-11**].
TECHNIQUE: Axial MDCT images were obtained from lung bases to
pubic symphysis after administration of 130 cc of Optiray
intravenously. Oral contrast was also used. Sagittal and coronal
reformatted images were then obtained.
CT OF THE ABDOMEN WITH IV CONTRAST: The visualized portion of
the lung bases demonstrate moderate bilateral pleural effusion,
right greater than left, which has worsened compared to the
prior CT of the chest. No pulmonary nodule is visualized.
Dependent atelectatic changes are noted at both lung bases. The
heart and great vessels have normal appearance.
The liver, gallbladder, spleen, adrenal glands, kidneys,
pancreas, have normal appearance. The stomach, duodenum proximal
small bowel loops including jejunum and proximal ileal loops
demonstrated diffuse wall thickening. this is most prominent
inthe stomach with infilteration of gastric wall with hypodense
material.
No pathologically enlarged mesenteric or retroperitoneal nodes
are noted. No free air is noted within the abdomen. Ascetic
fluid is surrounding the live.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder contains
a Foley catheter and small amount of air. The uterus contains
multiple cystic areas most likely representing degenerating
fibroids. The right adnexa contains a simple cyst. The left
adnexa is normal. The rectum is normal in appearance. The
sigmoid colon contain multiple diverticula with no evidence of
diverticulitis. A small amount of free fluid is noted within the
pelvis. No pathologically enlarged pelvic or inguinal nodes are
noted.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
noted.
IMPRESSION:
1. No pathologically enlarged mesenteric, retroperitoneal or
pelvic or inguinal nodes are noted.
2. Moderate bilateral pleural effusion, right greater than left
and moderate amount of ascites is noted in the peritoneal
cavity. This appearance is mostly consistent with third spacing.
3. Apparent diffuse hypodense thickening of the stomach.
Although this appearance is mostly due to contraction and fluid
overload, an underlying pathology such as gastric lymphoma can
not be excluded.
Brief Hospital Course:
Briefly this is a 48 year old female with h/o mitral
prolapse/mitral regurgitation, a recent dx of pneumonia, who
presented with worsening SOB/DOE and complaints of hearing loss.
During her hospitalization the patient was found to have
hypoxia responsive to supplemental 02, tachypnea with low lung
volumes, bilateral pleural effusions, tachycardia, elevated
LFTs, mediastinal lymphadenopathy, an abnormal MRI with
leptomeningeal enhancement, altered mental status, hearing loss,
abnormally cellular CSF and low platelets.
.
Hospital course by problem:
.
# Hypoxia: On admission the patient was noted to be hypoxic on
room air. She had a CTA which was negative for aortic
dissection and PE. Her cardiac enzymes were negative, she had
no ischemic changes on her EKG. She had completed ~ 5 days of
azithromycin at the time of admission for a presumed PNA which
was discontinued shortly after admission due to concerns that it
was the etiology for her c/o hearing loss. She triggered on the
floor for hypoxia on room air to the 60s and she was transferred
to the ICU. She was continued on levofloxacin for CAP coverage,
this was stopped after a total of 1 week fo abx after pt
developed thrombocytopenia. Pt at that point had never had
clear infiltrate on CXR, fevers, elevated WBC or sputum
production suspicious for a PNA. Her legionella antigen and
mycoplasma IgG were negative, mycoplasma IGM elevated. She had a
negative PPD. Her BNP was high normal and subsequent CXRs
showed findings suggestive of pulmonary edema, given her history
of MVP and MVR initially CHF was suspected and the patient was
treated with diuretics. She had A TTE which showed normal a EF,
2+ MR, MVP, no pulmonary hypertension, no pericardial effusion,
late bubble passage on bubble study c/w possible pulmonary avms.
Her hypoxia and tachycardia did not improve with diuresis, she
clinically appeared dry and she had urine lytes that were more
consistent with hypovolemia and she then underwent a trial of
fluid recusitation. She became somewhat less tachycardic, her
hypoxia was unchanged. She had a repeat CT chest which showed
less pulmonary edema, but persistent small pulmonary effusions
and mediastinal lymphadenopathy. She continued to have a ~5L 02
requirement, desaturating to low 70% when taken off 02. She was
transiently tried on NIPPV to assess whether this would improve
her lung volumes however the patient couldn't tolerate it. Her
negative inspiratory flow rate was low, but it was unclear it
this was artificially low due to poor patient cooperation. Her
B-glucan returned positive, but ID did not feel that this
warrented specific therapy by the time of discharge, when she
had shown significant overall clinical improvement. It was
re-sent and is pending at time of discharge.
After tranfer to the medical [**Hospital1 **] she slowly regained strength.
She spiked a fever and cultures from her PICC line showed GPCs
so this was removed, and vancomycin started. She defervesced.
Her cultures showed coagulase negative staph, felt to be a
contaminant, and her antibiotics were stopped and she did not
have recurrent fever. PT was aggressively initiated and her
bladder catheter removed with the hope that she would mobilize
the excess fluids and experience diminishment of her effusions
and lung expansion - there was some interval improvement but by
[**2111-5-22**] she still had significant effusions bilaterally on
examination, so a trial of diuresis was initiated. Three days
of diuresis did not result in significant change in pleural
effusions and was discontinued on day of discharge. Patient
satting in low to mid 90's with ambulation by discharge.
Repeat chest CT on [**5-24**] showed persistent effusions and
adenopathy, unchanged.
.
#CNS. The patient had a brain MRI due to concerns about her
symptoms of hearing loss as well as her altered mental status.
The MRI was significant for leptomeningeal enhancement involving
the auditory meatus. Both the infectious disease and neurology
teams were involved during the patients stay for assistance with
diagnostic management. The patient underwent 2 lumbar punctures
(repeated due to low CSF yield initially). The CSF was
significant for hypercellularity with a predominance of
activated lymphocytes, was not c/w CNS lymphoma. There was no
growth from bacterial, fungal or viral cultures. She was HIV
negative, ACE negative, CMV PCR negative, HHV6 negative, VZV PCR
negative, EBV was detected on PCR - this was felt to be
reactivation most likely of a remote process, and active
treatment was not pursued.
pending at time of discharge: CSF HSV PCR, Lyme EIA, (although
serum serologies were negative), VDRL (serum RPR positive).
Her hearing loss and mental status improved prior to transfer
out of the ICU; the etiology of her meningitic process remained
unclear. [**Name2 (NI) **] likely, it was felt to represent a post
infectious process from either a mycoplasma pneumonia or other
pneumonia, or a viral meningitis in which the virus was not
isolated. Neurology recommended: repeat LP for another cytology
specimen and for ACE level over concern for malignancy or
sarcoidosis, however the pt. refused further evaluation, tests,
or LP at this time, so this was not done. This was discussed
with her primary care doctor, who agreed to hold off on further
testing/evaluation given her overall clinical improvement, and
to investigate further as an outpatient as indicated given her
outpatient, future, clinical course.
.
Outpatient infectious disease clinic follow up was arranged.
.
#LFTs - Upon admission to the ICU on [**5-11**] the patient's LDH and
transaminases were elvated in the thousands. She was HCV
negative, HBV negative, had + HAV IgG, negative IgM. [**Doctor First Name **] was
positive with a relatively low titer of 1:160. Her anti-smooth
muscle antibody was negative. CMV serologies negative in serum,
EBV IgG positive, IgM negative. Hepatology was consulted and
recommend that she be treated empirically with doxycycline for
leptospirosis, however leptospira ab ended up returning
negative. Ceruloplasmin was WNL, however urinary copper was
elevated - this was discussed with the liver team, who stated
that any hepatocellular injury leads to increased urinary copper
excretion as the hepatocytes are full of copper (in normalcy) -
they recommended that this be repeated once acute issues have
resolved, however, they stated that Wilsons disease is extremely
unlikely in this pt. given age and lack of cirrhosis and the
fact that ceruloplasmin was normal. Ferritin markedly elevated
with elevated Fe/TIBC ratio however HHC mutation studies were
negative. She had a liver u/s which showed mildly echogeneic
liver, patent vessels, borderline enlarged spleen, absence of
ascites. Her LFTs trended down to near normal levels prior to
her discharge. She did have a low albumin and a slight
elevation in her PT/INR during her stay but it was unclear if
this was a representation of hepatic synthetic function versus
nutritional deficiency in setting of poor PO intake and
antibiotics use.
A CT abd/pelvis were done which showed known small pleural
effusions, thickened stomach, possibly related to
overdistention, normal liver and spleen. No lymphadenopathy
noted. Her transaminitis improved.
.
#Thrombocytopenia: Platelets were low at 128 on admission with a
nadir of 54 on [**5-14**], normalized subsequently prior to discharge.
DIC panel negative. There was concern that her transient
thrombocytopenia may had been a medication effect. The timing
of her drop was not consistent with HIT, and improved.
.
On discharge, the following issues were not yet resolved, and
will need follow up from her primary care doctor:
.
* Follow up for her [**First Name9 (NamePattern2) 9374**] [**Doctor First Name **] (possible rheumatologic
evaluation), anti DS DNA and Anti [**Doctor Last Name 1968**] ab among others pending
and rheumatology appointment scheduled
* Follow up of serologies (multiple) that were sent and pending
at the time of discharge. ID follow up scheduled. Positive RPR
needs follow up, treponemal confirmatory ab pending.
* Consideration of repeat evaluation of identified mediastinal
adenopathy with repeat chest CT and further workup as
appropriate. Last CT on [**5-24**]
At the time of this discharge, clinical syndrome felt likely to
be viral process or possibly mycoplasma infection but
rheumatologic etiologies remain in the differential.
Additionally, given lymphadenopathy, hematologic abnormalities,
malignancy remains on the differential. Rheumatologic and
oncologic diagnosis seem less likely given overall improvement
without specific treatment aimed at such a disease. MAny
laboratory tests sent in the hospital are pending at time of
discharge. Patient prefers to defer further investigations as
long as she continued to clinically improve. This was discussed
with her pcp, [**Name10 (NameIs) 1023**] understood and agreed.
Rheumatology and infectious disease follow up in place for the
patient.
Medications on Admission:
imitrex prn
omeprazole 40mg daily
ativan 0.5mg qhs prn
Discharge Medications:
1. three in one commode Sig: One (1) commode as needed.
Disp:*1 commode* Refills:*0*
2. shower chair Sig: One (1) chair as needed.
Disp:*1 chair* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Imitrex 50 mg Tablet Sig: 1-2 Tablets PO Q 2 hours prn as
needed for headache: [**1-21**] Tablet(s) by mouth Q 2 Hr as needed for
H/A not to exceed 300 mg every day .
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Leptomeningeal process/meningitis, etiology unclear, felt most
likely to be a post infectious meningitis
Hypoxia due to pulmonary edema
Mitral valve prolapse
Bacterial pneumonia
Malnutrition
Generalized deconditioning
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. Call Dr. [**Last Name (STitle) **] or return
to the [**Hospital1 18**] Emergency Department for:
Fevers
Worsening shortness of breath
Headaches or neck stiffness
Visual changes
Confusion
Chest pain
Any other acute concerns
Followup Instructions:
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2111-5-26**] 12:10
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2111-6-5**]
11:30
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,855
| 149,991
|
41874+58482
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-2-2**] Discharge Date: [**2145-2-17**]
Date of Birth: [**2074-8-1**] Sex: M
Service: NEUROSURGERY
Allergies:
simvastatin / Ciprofloxacin / Glumetza / lisinopril /
Methotrexate
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
[**2145-2-9**] Bilateral Bur hole evacuation of Subdural Hematoma
History of Present Illness:
Mr. [**Known lastname 22254**] is a 70M w/ history of Burkitt's lymphoma with
progressive disease, currently receiving IVAC chemo C2D12 who
presents from [**Hospital **] clinic with headache, found to have
spontaneous SDH. Patient was seen for routine heme-onc checkup
today complaining of headache. Patient received CT head and was
found to have bilateral subdural hemorrhage with midline shift.
Patient's platelets were 7 and he was given one unit of
platelets at that time. Patient was transferred to the ED for
admission and neurosurgery evaluation. He denies blurry vision,
numbness (other than chronic chin numbness), tingling, weakness
of the extremities (outside of chronic weakness which has been
attributed to vincristine toxicity, and compression neuropathy
due to weight loss). He states the headache is pretty mild, has
been located over occiput, midline but is currently frontal. He
denies nausea, vomiting. Patient denies any history of trauma -
falls or bumping head. But notes a remote fall in [**Month (only) 359**] of
[**2144**], for which head CT was negative. Wife notes that his voice
has sounded different but that it typically sounds this way
after receiving chemotherapy.
.
In the ED, VS 97.2 90 127/80 20 98%, HA [**2-26**]. Neuro exam was
nonfocal, patient A&Ox3. Labs significant for pancytopenia (WBC
0.1, ANC 80, hct 21.4, plts 7), electrolytes and coags WNL (INR
0.9). EKG showed sinus @ 90, no acute changes. Patient was
transfused an additional 1 unit of platelets. Neurosurgery was
consulted, and recommended no acute intervention at this time,
but stated they will follow patient during admission and give
further recs. Dr. [**First Name (STitle) **] was updated about the patient and plan
for [**Hospital Unit Name 153**] admission for q2h neuro checks. VS prior to transfer
98.3 HR 94 BP 118-103/78 RR 18 O2 sat 98-100% RA.
.
On arrival to the ICU, VS 98.6, 120/64, 93, 14, 99% RA. Patient
was comfortable without complaints aside from mild [**2-26**] frontal
HA. Denies f/c, cough, chest pain, oropharyngeal discomfort,
dysuria, abdominal pain, change in bowel movements (notes
intermittent diarrhea, recent h/o c.diff).
Review of systems:
(+) Per HPI. Notes new skin breakdown and scabbing over left 2nd
MCP joint and right forearm.
(-) Denies fever, chills. Denies sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, 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:
Burkitt's lymphoma
DM
HTN
sarcoid
ischemic colitis
hyperlipidemia
.
Oncological History
- [**2144-7-17**]: numbness and pain right jaw and chin, night sweats,
right neck mass and weight loss.
- [**2144-8-22**] PET CT with FDG avid R neck mass and numerous liver
lesions. Biopsy of the neck mass c/w aggressive B cell
lymphoma. ECHO with EF 55%.
- [**2144-9-2**] BMBx revealed hypercellular marrow with >95%
replacement with high grade B cell lymphoma. M:E ratio cannot be
assessed. Flow cytometry showed monotypic large B cells, kappa
light chain restricted, CD10+, CD19+, CD20+ bright, CD22+, CD
38+
bright, FMC7+, CD5-, CD11c-, CD25-, CD103-. Cytogenetics with
t(8:14) cMYC-IgH. Consistent with involvement by Burkitt's
lymphoma.
- [**2055-9-8**] C1D1 R-CHOP in outside hospital(rituximab 750 mg,
cyclophosphamide 1500 mg, doxorubicin 100 mg, vincristine 2 mg,
dexamethasone 8 mg) with Neulasta on D2.
- [**9-26**] IT cytarabine
- [**9-26**] high dose methotrexate (3500 mg/m2), complicated by acute
kidney injury
- [**10-4**] Rituximab 100 mg
- [**10-8**] C1 [**Hospital1 **] (Etoposide 45 mg/m2 D1-4, Doxorubicin 10 mg/m2
D1-4, Vincristine 0.4 mg/m2 D1-4, Cyclophosphamide 750 mg/m2 D5)
- [**10-24**] Rituximab 375 mg/m2
- [**10-28**] C2 [**Hospital1 **] (Etoposide 60 mg/m2 D1-4, Doxorubicin 12 mg/m2
D1-4, Vincristine 0.4 mg/m2 D1-4, Cyclophosphamide 900 mg/m2 D5)
- [**10-29**] IT cytarabine
- [**2144-11-22**] C3 [**Hospital1 **] (Etoposide 70 mg/m2 D1-4, Doxorubicin 12
mg/m2 D1-4, Vincristine 0.4 mg/m2 D1-4, Cyclophosphamide 1050
mg/m2 D1)
- [**12-9**] IT methotrexate
- [**2144-12-16**] C4 DA-[**Hospital1 **] (Etoposide 60 mg/m2 D1-4, Doxorubicin
10
mg/m2 D1-4, Vincristine 0.3 mg/m2 D1-4, Cyclophosphamide 900
mg/m2 D5)
- [**2144-12-16**] Rituximab
- [**1-1**] restaging PET showed disease progression with increased
size and FDG-avidity of residual right neck mass and new
FDG-avidity of mediastinal, hilar, right supraclavicular,
epicardial fat pad, right submandibular space, and portacaval
lymphadenopathy. There was also new focal FDG uptake in the L4
vertebral body and left humeral head are also consistent with a
neoplastic process.
[**2145-1-4**] cycle 1 of IVAC. Biopsy of the cervical FDG avid lymph
node, shows lymphoma cells.
- [**2145-1-22**] cycle 2 IVAC
Social History:
Smoked 1ppd x five years around age 30, does not drink or use
drugs, lives with wife and 2 grown children live nearby, worked
as a limo driver
Family History:
Sister with [**Name2 (NI) 500**] cancer, sister with bilateral breast cancer,
brother with unspecified cancer, heart disease in father. [**Name (NI) **]
recently diagnosed with lymphoma, over [**Holiday **].
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: VS 98.6, 120/64, 93, 14, 99% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
without lesions
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, nonerythematous port
in right upper chest, no wheezes, rales, rhonchi
CV: mildly tachycardia, regular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses in DP, no clubbing, cyanosis
or edema
Neuro: A&Ox3, very sharp, CN II-XII intact with the exception of
diminished sensation in V3 bilaterally and inability to smile
[**2-18**] numbness of chin. Strength 5/5 in all extremities. Sensation
[**5-22**] to light touch and temperature in all extremities. 2+
brachioradialis and patella reflexes bilaterally. Cerebellar
function intact.
Discharge PE: He has two scalp incisions with sutures and the
right has 2 staples from drain removal. He has chronic peri-oral
numbness. He has no motor or CN deficit
Pertinent Results:
LABS:
On admission:
[**2145-2-2**] 09:55AM BLOOD WBC-0.1* RBC-2.49* Hgb-7.8* Hct-21.4*
MCV-86 MCH-31.1 MCHC-36.3* RDW-13.8 Plt Ct-7*#
[**2145-2-2**] 09:55AM BLOOD Neuts-80* Bands-0 Lymphs-12* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2145-2-2**] 01:36PM BLOOD PT-10.2 PTT-28.2 INR(PT)-0.9
[**2145-2-2**] 10:00AM BLOOD UreaN-18 Creat-0.5 Na-138 K-4.2 Cl-102
HCO3-27 AnGap-13
[**2145-2-2**] 05:40PM BLOOD ALT-17 AST-16 LD(LDH)-102 AlkPhos-92
TotBili-0.7
[**2145-2-2**] 05:40PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.6# Mg-1.9
IMAGING:
CT head:
IMPRESSION: New bilateral right greater than left
frontoparietal, subfalcine, and supratentorial subdural
hematomas of mixed chronicity, causing 8 mm of leftward shift of
normally midline structures. No intra-axial hemorrhage.
Underlying neoplastic disease is poorly assessed on current
study.
.
CXR [**2-9**]: Heterogeneous opacification in the left lower lung
could represent early effect of aspiration. Right hilar
adenopathy has increased. Heart size is normal. There is no
appreciable pleural effusion or pneumothorax. A bulging
mediastinal contour in the region of the ascending aorta could
be due to adenopathy or a tortuous or dilated aorta. Right
subclavian infusion port ends low in the SVC.
.
[**2-9**] CT Head:
1. Status post evacuation of bilateral subdural hematomas, with
small
residual bilateral hemispheric subdural collections, and
interval decrease in mass effect upon the cerebral hemispheres.
2. Large amount of pneumocephalus, in the interhemispheric
fissure, extending between the frontal lobes, concerning for
"tension pneumocephalus," which should be correlated clinically.
[**2-10**] CT head
1. Enlargement of the left subdural collection with mild mass
effect, but no evidence of herniation.
2. Decreased amount of post-surgical pneumocephalus.
3. Stable size of small right subdural hematoma.
Brief Hospital Course:
This is a 70 year old man with a PMH of HTN, DM, Burkitt's
lymphoma with progressive disease, who was receiving IVAC chemo
C2D12 (on admission) with pancytopenia who presented with
headache. CT head showed bilateral subacute SDH. He was
transferred from [**Hospital Unit Name 153**] to BMT service, after worsening headaches,
N/V, and depressed level of consciousness, was transferred to
SICU after burr holes for evacuation of b/l sub-dural hematomas.
.
# SDH: Monitored in [**Hospital Unit Name 153**] and then BMT service. It was felt that
some component of his headache may have been related to post-LP
given positional nature (patient had LP 1 week prior to
admission), however given his clinical deterioration, it became
apparent that this was unlikely. Chronic lower lip numbness and
b/l ankle weakness (chronic) were his only apparent neurological
deficits noted. He had persistent headaches and nausea, patient
received multiple head CTs, which were stable until [**2-9**] when
midline shift increased, and patient became more lethargic. He
also had persistent emesis. Neurosurgery re-evaluated the
patient and felt that surgical intervention was indicated, and
the patient was subsequently trasferred to the OR and he
underwent bilateral bur hole evacuation of the SDH's with a
subdural drain left on the right. Post-op CT showed
pneumocephalus as expected. He was recovering well on [**2-10**] and
CT head showed some more left SDH but less midline shift. He was
seen by PT who recommended home with PT services. He was
trasnfered to the floor when a bed was available on [**2-11**]. He had
some dizziness and nausea when elevated with PT. He continued to
be observed. He was screened for rehab as it was felt that he
was not strong enough to care for himself while alone during the
day. He was DC'd to rehab in stable condition and will follow up
as directed by discharge paperwork.
#Leukocytosis: An infectious work-up was initiated given his
somnolence and leukocytosis (persistent elevation after neupogen
was discontinued on [**2-7**]). He WBC count did trend down to 11 on
[**2-11**]. He was afebriel and was contniued on Bactrim and
antivirals. Blood culture from [**2-9**] showed....C diff was
negative x 3 and contact precautions were lifted. CXR from [**2-9**]
showed a left lung consolidation and CXR was repeated
showing....
.
# Pancytopenia/neutropenia: Patient was C2D12 of IVAC on
admission with an ANC of 80, transfused to maintain hemoglobin
>8 and platelets >50, by the time of transfer to SICU, his
counts had recovered. Platelets were 119 at time of the surgery
and raised to 159 on [**2144-2-12**].
.
# Burkitts Lymphoma: Patient initially diagnosed in [**8-28**]. Recent
PET showed disease progression. US guided biopsy of a right
cervical lymph node on [**1-8**] showed malignant cells. He was
continued on acyclovir, bactrim, voriconazole for prophylaxis.
Outpatient erstaging PET CT was arranged.
.
# DMII: No HgbA1c in OMR. Metformin was held and patient was
managed on ISS. Kidney function was normal on [**2-11**] and Metformin
was restarted after speaking with the BMT resident.
.
# Hypertension: Continued home metoprolol 12.5 [**Hospital1 **], amlodipine
5mg Qday, quinapril was decreased to 20mg qday.
.
# Sarcoid: stable, not being actively managed as an outpatient.
.
# Hyperlipidemia: No results on the computer, not being actively
managed as an outpatient.
=====
Transitional issues:
-Quinapril decreased to 20mg daily
-
Medications on Admission:
acyclovir 400 mg Tablet TID
amlodipine 5 mg Tablet DAILY
folic acid 1 mg Tablet daily
metformin 500 mg Tablet [**Hospital1 **]
metoprolol tartrate 12.5 mg [**Hospital1 **]
oxycodone 5 mg Tablet TID prn pain
prochlorperazine maleate 10 mg Tablet q6h prn nausea
quinapril 40 mg Tablet DAILY
saliva substitution combo no.2 QID
sulfamethoxazole-trimethoprim 400 mg-80 mg Tablet daily
voriconazole 200 mg Tablet [**Hospital1 **]
calcium carbonate 200 mg calcium (500 mg) Tablet Chewable TID
cyanocobalamin (vitamin B-12) 100 mcg Tablet daily
Neupogen 480mg SC daily
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
12. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
14. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Subdural hematomas
Brain compression
Neutropenia
Thrombocytopenia
Gait disturbance
Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Instructions for Follow up: Subdural, Epidural Hemorrhages
Surgical
Dr. [**Last Name (STitle) 24275**] [**Name (STitle) 739**]
You were admitted for Subdural Hematomas and had a surgical
procedure to relieve the pressure on your brain.
You are now on an anti-epileptic medication as these blood
collections could cause a seizure.
Please note the following medication changes:
-Please DECREASE your Quinapril to 20mg daily
-Please STOP taking neupogen unless instructed to start again by
your outpatient doctors.
?????? Keep your staples clean and dry until they are removed.
?????? Have a friend or family member check the wound for signs of
infection such as redness or drainage daily.
?????? Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
?????? Exercise should be limited to walking; no lifting >10lbs,
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.
?????? DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
not safely resume taking this until follow up in one month.
?????? You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine; you will not require blood work
monitoring.
?????? Do not drive until your follow up appointment.
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:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with one
of the Physician Assistants on [**2-17**] for staple removal.
You can come before your Pet CT.
??????You need to see Dr. [**Last Name (STitle) 739**] in 4 weeks. You will need a
CT scan of the brain without contrast prior to your appointment.
This can be scheduled when you call to make your office visit
appointment.
You will have a PET CT on [**2145-2-17**] at 2pm, [**Location (un) **] [**Hospital Ward Name 23**] Bld,
[**Hospital Ward Name 516**]. The prep with info for your diet the night before
and morning of the test will be with your discharge
papers.DIVISION OF NUCLEAR MEDICINE([**Telephone/Fax (1) 2103**]
You have an appt with Dr.[**First Name (STitle) **] or [**First Name (STitle) **] in oncology on [**2-22**] at
1:30 p.m.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2145-2-12**] Name: [**Known lastname 14340**],[**Known firstname 3874**] Unit No: [**Numeric Identifier 14341**]
Admission Date: [**2145-2-2**] Discharge Date: [**2145-2-17**]
Date of Birth: [**2074-8-1**] Sex: M
Service: NEUROSURGERY
Allergies:
simvastatin / Ciprofloxacin / Glumetza / lisinopril /
Methotrexate
Attending:[**First Name3 (LF) 1698**]
Addendum:
See below.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2145-2-9**] Bilateral Bur hole evacuation of Subdural Hematoma
History of Present Illness:
Mr. [**Known lastname **] is a 70M w/ history of Burkitt's lymphoma with
progressive disease, currently receiving IVAC chemo C2D12 who
presents from [**Hospital 14342**] clinic with headache, found to have
spontaneous SDH. Patient was seen for routine heme-onc checkup
today complaining of headache. Patient received CT head and was
found to have bilateral subdural hemorrhage with midline shift.
Patient's platelets were 7 and he was given one unit of
platelets at that time. Patient was transferred to the ED for
admission and neurosurgery evaluation. He denies blurry vision,
numbness (other than chronic chin numbness), tingling, weakness
of the extremities (outside of chronic weakness which has been
attributed to vincristine toxicity, and compression neuropathy
due to weight loss). He states the headache is pretty mild, has
been located over occiput, midline but is currently frontal. He
denies nausea, vomiting. Patient denies any history of trauma -
falls or bumping head. But notes a remote fall in [**Month (only) 5298**] of
[**2144**], for which head CT was negative. Wife notes that his voice
has sounded different but that it typically sounds this way
after receiving chemotherapy.
.
In the ED, VS 97.2 90 127/80 20 98%, HA [**2-26**]. Neuro exam was
nonfocal, patient A&Ox3. Labs significant for pancytopenia (WBC
0.1, ANC 80, hct 21.4, plts 7), electrolytes and coags WNL (INR
0.9). EKG showed sinus @ 90, no acute changes. Patient was
transfused an additional 1 unit of platelets. Neurosurgery was
consulted, and recommended no acute intervention at this time,
but stated they will follow patient during admission and give
further recs. Dr. [**First Name (STitle) **] was updated about the patient and plan
for [**Hospital Unit Name 1863**] admission for q2h neuro checks. VS prior to transfer
98.3 HR 94 BP 118-103/78 RR 18 O2 sat 98-100% RA.
.
On arrival to the ICU, VS 98.6, 120/64, 93, 14, 99% RA. Patient
was comfortable without complaints aside from mild [**2-26**] frontal
HA. Denies f/c, cough, chest pain, oropharyngeal discomfort,
dysuria, abdominal pain, change in bowel movements (notes
intermittent diarrhea, recent h/o c.diff).
He was monitored in [**Hospital Unit Name 1863**] and then BMT service. It was felt that
some component of his headache may have been related to post-LP
given positional nature (patient had LP 1 week prior to
admission), however given his clinical deterioration, it became
apparent that this was unlikely. Chronic lower lip numbness and
b/l ankle weakness (chronic) were his only apparent neurological
deficits noted. He had persistent headaches and nausea, patient
received multiple head CTs, which were stable until [**2-9**] when
midline shift increased, and patient became more lethargic. He
also had persistent emesis. Neurosurgery re-evaluated the
patient and felt that surgical intervention was indicated, and
the patient was subsequently trasferred to the OR and he
underwent bilateral bur hole evacuation of the SDH's with a
subdural drain left on the right. Post-op CT showed
pneumocephalus as expected. He was recovering well on [**2-10**] and
CT head showed some more left SDH but less midline shift. He was
seen by PT who recommended home with PT services. He was
trasnfered to the floor when a bed was available on [**2-11**]. He had
some dizziness and nausea when elevated with PT.
The patient was felt by the Neurosurgery service to be well
enough for discharge on [**2-12**]; however, BMT requested that he be
transferred back to their service for further managment of
headaches and nausea. On arrival to the floor, he stats he has a
frontal headache which is [**4-27**] inintensity but similar to that
he had before. He also complained of some nausea which resolved
with medication. He otherwise feels well.
Review of systems:
(-) Denies fever, chills. Denies sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies 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:
Burkitt's lymphoma
DM
HTN
sarcoid
ischemic colitis
hyperlipidemia
.
Oncological History
- [**2144-7-17**]: numbness and pain right jaw and chin, night sweats,
right neck mass and weight loss.
- [**2144-8-22**] PET CT with FDG avid R neck mass and numerous liver
lesions. Biopsy of the neck mass c/w aggressive B cell
lymphoma. ECHO with EF 55%.
- [**2144-9-2**] BMBx revealed hypercellular marrow with >95%
replacement with high grade B cell lymphoma. M:E ratio cannot be
assessed. Flow cytometry showed monotypic large B cells, kappa
light chain restricted, CD10+, CD19+, CD20+ bright, CD22+, CD
38+
bright, FMC7+, CD5-, CD11c-, CD25-, CD103-. Cytogenetics with
t(8:14) cMYC-IgH. Consistent with involvement by Burkitt's
lymphoma.
- [**2055-9-8**] C1D1 R-CHOP in outside hospital(rituximab 750 mg,
cyclophosphamide 1500 mg, doxorubicin 100 mg, vincristine 2 mg,
dexamethasone 8 mg) with Neulasta on D2.
- [**9-26**] IT cytarabine
- [**9-26**] high dose methotrexate (3500 mg/m2), complicated by acute
kidney injury
- [**10-4**] Rituximab 100 mg
- [**10-8**] C1 [**Hospital1 170**] (Etoposide 45 mg/m2 D1-4, Doxorubicin 10 mg/m2
D1-4, Vincristine 0.4 mg/m2 D1-4, Cyclophosphamide 750 mg/m2 D5)
- [**10-24**] Rituximab 375 mg/m2
- [**10-28**] C2 [**Hospital1 170**] (Etoposide 60 mg/m2 D1-4, Doxorubicin 12 mg/m2
D1-4, Vincristine 0.4 mg/m2 D1-4, Cyclophosphamide 900 mg/m2 D5)
- [**10-29**] IT cytarabine
- [**2144-11-22**] C3 [**Hospital1 170**] (Etoposide 70 mg/m2 D1-4, Doxorubicin 12
mg/m2 D1-4, Vincristine 0.4 mg/m2 D1-4, Cyclophosphamide 1050
mg/m2 D1)
- [**12-9**] IT methotrexate
- [**2144-12-16**] C4 DA-[**Hospital1 170**] (Etoposide 60 mg/m2 D1-4, Doxorubicin
10
mg/m2 D1-4, Vincristine 0.3 mg/m2 D1-4, Cyclophosphamide 900
mg/m2 D5)
- [**2144-12-16**] Rituximab
- [**1-1**] restaging PET showed disease progression with increased
size and FDG-avidity of residual right neck mass and new
FDG-avidity of mediastinal, hilar, right supraclavicular,
epicardial fat pad, right submandibular space, and portacaval
lymphadenopathy. There was also new focal FDG uptake in the L4
vertebral body and left humeral head are also consistent with a
neoplastic process.
[**2145-1-4**] cycle 1 of IVAC. Biopsy of the cervical FDG avid lymph
node, shows lymphoma cells.
- [**2145-1-22**] cycle 2 IVAC
Social History:
Smoked 1ppd x five years around age 30, does not drink or use
drugs, lives with wife and 2 grown children live nearby, worked
as a limo driver
Family History:
Sister with [**Name2 (NI) **] cancer, sister with bilateral breast cancer,
brother with unspecified cancer, heart disease in father. [**Name (NI) **]
recently diagnosed with lymphoma, over [**Holiday 14343**].
Physical Exam:
T 98.9 bp 156/80 HR 74 RR 18 SaO2 97RA
General: Alert, oriented, no acute distress
HEENT: Pupils equal at 5mm, EOMI, Sclera anicteric, MMM,
oropharynx clear without lesions, incisions on scalp stapled
without evidence of erythema or pus
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, nonerythematous port
in right upper chest, no wheezes, rales, rhonchi
CV: regular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses in DP, no clubbing, cyanosis
or edema
Neuro: A&Ox3, no focal deficits
Pertinent Results:
Discharge Labs:
[**2145-2-17**] 12:00AM BLOOD WBC-7.5 RBC-3.07* Hgb-9.6* Hct-27.9*
MCV-91 MCH-31.4 MCHC-34.5 RDW-16.7* Plt Ct-269
[**2145-2-17**] 12:00AM BLOOD Neuts-85.7* Lymphs-4.8* Monos-9.1 Eos-0.3
Baso-0.2
[**2145-2-17**] 12:00AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-141
K-4.4 Cl-104 HCO3-30 AnGap-11
CT HEAD W/O CONTRAST [**2145-2-14**]
FINDINGS: Overall, bilateral extra-axial subdural fluid
collections appear
stable to slightly decreased on this examination. The degree of
pneumocephalus is clearly improved. The patient is status post
bifrontal
craniotomies. Areas of hyperdensity subjacent to the inner table
at the
craniotomy sites appear unchanged (2:23), possibly
post-procedure related
clot. An area of hyperdensity along the left convexity (2:16) is
also
unchanged. No new foci of hyperdensity to suggest interval
hemorrhage are
seen.
Minimal midline shift, less than 2 mm to the left, is unchanged.
There is
edema and sulcal effacement with mass effect on the ventricles
as compared to the CT of [**2144-8-2**], which was obtained prior
to the hemorrhage. The ventricles and suprasellar cistern
however appear similar to the prior
examination. An ovoid hypodensity in the region of the right
cerebellar
hemisphere appears unchanged and may be related to extra-axial
fluid.
No concerning osseous lesion is seen. The visualized paranasal
sinuses and
mastoid air cells are clear.
IMPRESSION: Stable to slightly-decreased size of bilateral
extra-axial
subdural fluid collections. No new foci of hemorrhage
identified. Decreased pneumocephalus.
NOTE ADDED IN ATTENDING REVIEW: As above, there is a somewhat
ill-defined 2.6 (AP) x 2.1 cm (TRV) fluid-attenuation collection
in the right superior aspect of the posterior fossa, with slight
mass effect on the subjacent cerebellar hemisphere (2:[**11-29**]).
While of slightly more fluid-attenuation over the series of
studies since [**2145-2-2**], it is not clearly present on MR studies
of [**9-26**] and [**2144-12-11**], and may represent a relatively acute
posterior fossa subdural hygroma.
Brief Hospital Course:
SUMMARY:
70M w/ PMH of HTN, DM, Burkitt's lymphoma with progressive
disease, currently receiving IVAC with pancytopenia who presents
with headache, found to have spontaneous SDH, stable CT imaging,
s/p transfer from [**Hospital Unit Name 1863**].
# SDH: Stable on repeat CT imaging, although his HA and nausea
persisted. He was started on PO prednisone 40mg daily, and his
symptoms significantly improved. On discharge he was instructed
to taper prednisone to 10mg daily and to follow up with Dr.
[**First Name (STitle) **] in 1 week post-discharge. Neurosurgery evaluated his
surgical incisions and removed his staples on day of discharge.
He was evaluated by PT and felt safe to return home. He will
have repeat head CT in 4 weeks and follow up in neurosurgery
clinic.
# Burkitts Lymphoma: Patient initially diagnosed in [**8-28**]. Recent
PET showed disease progression. He was continued on his home
acyclovir, bactrim, and voriconazole. He is scheduled for
repeat PET on [**2145-2-24**] and to follow up with Dr. [**First Name (STitle) **] in clinic
on the same day.
Rest of hospital course as described above.
Medications on Admission:
acyclovir 400 mg Tablet TID
amlodipine 5 mg Tablet DAILY
folic acid 1 mg Tablet daily
metformin 500 mg Tablet [**Hospital1 **]
metoprolol tartrate 12.5 mg [**Hospital1 **]
oxycodone 5 mg Tablet TID prn pain
prochlorperazine maleate 10 mg Tablet q6h prn nausea
quinapril 40 mg Tablet DAILY
saliva substitution combo no.2 QID
sulfamethoxazole-trimethoprim 400 mg-80 mg Tablet daily
voriconazole 200 mg Tablet [**Hospital1 **]
calcium carbonate 200 mg calcium (500 mg) Tablet Chewable TID
cyanocobalamin (vitamin B-12) 100 mcg Tablet daily
Neupogen 480mg SC daily
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
12. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. prednisone 10 mg Tablet Sig: Taper per instructions PO once
a day: Take 3 tablets for 3 days, then 2 tablets for 2 days,
then one tablet daily until you see Dr. [**First Name (STitle) **] in clinic.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
Discharge Diagnosis:
Subdural hematomas
Neutropenia
Thrombocytopenia
Gait disturbance
Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 8**] because you developed a bleed in your
brain. This likely happened because your platelets were very
low due to your chemotherapy. You had a surgical procedure to
remove the blood and were started on steroids to decrease
inflammation.
Please note the following medication changes:
-Please DECREASE your Quinapril to 20mg daily
-Please STOP taking neupogen unless instructed to start again by
your outpatient doctors.
-START prednisone: take 30mg for 2 days, then 20mg for 2 days,
then decrease to 10mg and follow up with Dr. [**First Name (STitle) **] about when to
stop.
Recommendations from Neurosurgery:
?????? Have a friend or family member check the wound for signs of
infection such as redness or drainage daily.
?????? Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
?????? Exercise should be limited to walking; no lifting >10lbs,
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.
?????? DO NOT take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
not safely resume taking this until follow up in one month.
?????? You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine; you will not require blood work
monitoring.
?????? Do not drive until your follow up appointment.
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.
Please see below for your upcoming appointments.
It has been a pleasure taking care of you at [**Hospital1 8**] and we wish
you a speedy recovery.
Followup Instructions:
Follow-Up Appointment Instructions
??????You need to see Dr. [**Last Name (STitle) **] in 4 weeks. You will need a
CT scan of the brain without contrast prior to your appointment.
This can be scheduled when you call to make your office visit
appointment.
You will have a PET CT on [**2145-2-24**] at 2pm, [**Location (un) **] [**Hospital Ward Name **] Bld,
[**Hospital Ward Name 600**]. The prep with info for your diet the night before
and morning of the test will be with your discharge
papers.DIVISION OF NUCLEAR MEDICINE([**Telephone/Fax (1) 14344**]
[**2145-2-24**] 12:00p [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Create Visit Summary
[**2145-2-24**] 12:00p BATTELLI,[**Last Name (un) 14345**]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEM/ONC FELLOWS
[**2145-2-24**] 12:00p [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Create Visit Summary
[**2145-2-24**] 12:00p BATTELLI,[**Last Name (un) 14345**]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEM/ONC FELLOWS
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2145-2-17**]
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40,978
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Discharge summary
|
report
|
Admission Date: [**2177-8-11**] Discharge Date: [**2177-9-13**]
Date of Birth: [**2110-7-24**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
[**2177-9-10**] Percutaneous gastrostomy tube
[**2177-8-12**] Transplant nephrectomy
History of Present Illness:
All H/P taken from OSH records in conjunction to talking to NH
and OSH staff. Code status at OSH full code.
Briefly 67F ESRD s/p deceased donor tx in [**2176**] by Dr. [**First Name (STitle) **].
Was followed in our system until late [**2176**] when she transfered
care to a rehab facility ([**Hospital1 1562**] Care Rehab). Over the past
week, the staff has been noticing waxing and [**Doctor Last Name 688**] mental
status from baseline (somewhat demented at baseline). She was
ultimately transferred to [**Hospital 1562**] hospital where she was
hypotensive in the 80's, bradycardic to the 40's, and
hypothermic (89 degrees per rectal probe). Atropine was given
as her HR dropped to the 20 which she responded to. Pressors
were started (Dopamine and Levaphed) for her hypotension. Vanco
and Levaquin X 1 were given. A foley was placed with immediate
return of cloudy purulent fluid. A CT scan without contrast was
done showing air in her transplanted kidney. No abscess was
seen. In preparation for ICU transfer at [**Hospital1 1562**], a right
quinton femoral line was placed in anticipation for HD. A RIJ
was also placed.
The patient was then transferred to [**Hospital1 18**]. In the ED she was
hypothermic, hypotensive despite being on pressors. She
recieved Flagyl. She was quickly transferred to the SICU and
intubated.
In terms of her transplant, the patient recieves her care at
[**Hospital1 1562**]. Her nephrologist is Dr. [**Last Name (STitle) 68844**] at Mashby Dialysis
(sp?). Per reports she has not been on dialysis since her
transplant.
Past Medical History:
DM type I c/b neuropathy, retinopathy, ESRD
ESRD s/p cadaveric renal transplant [**3-16**] c/b LLE arterial
thrombus s/p angioplasty and stent, on coumadin
HTN
Depression
Hypothyroidism
Peripheral vascular disease
GERD
Esophagitis
s/p R CEA
s/p L heel debridement and calcanectomy [**7-16**]
s/p removal of peritoneal dialysis cath & removal R IJ PermCath
[**3-16**] - Renal tx
[**4-16**] - Angioplasty of Left SFA, popliteal, tibioperoneal and
peroneal arteries and anterior tibial, Stenting of the
below-the-knee popliteal and tibioperoneal trunk
Social History:
Previously lived her husband but has been living in rehab since
transplant in [**3-16**]. Quit smoking over 10 years ago, 45 pack year
history. Rarely drinks and denies illicit drug use.
Family History:
heart disease, diabetes
Physical Exam:
(In ED): 33.8, 65, 95/39, 15, 100 NC
On pressors: Dopamine at 20, Levaphed 0.5, right IJ in
Confused, obeys commands, MAE X 4
RRR
Crackles right base
Soft/ND/NT, surgical scar well healed, kidney palpated, no
surrounding erythema/crepitus, has right femoral dialysis cath
in
no c/c/e
Pertinent Results:
Labs on admission:
WBC: 8.2 (94 PMNs with 1 band) Hct: 31.7 Plt: 175
PT: 13.4 PTT: 60.3 INR: 1.1
Chem 10: 140/3.5/122/5/61/5.0/166/ no Ca/1.8/5.8
Alt: 17 AST: 10 AP: 153 TB: 0.1 Lipase: 38
CK: 32, Trpn: 0.05 Lactate: 1.9
UA: grossly positive, many bacteria, mod leuko, > 50 WBC
CT Abd/Pelvis OSH - 12mm collection of air in the transplant
right pelvic kidney pelvis, may be [**2-10**] foley instrumentation;
however, given clinical history of puss draining from bladder
cannot exclude abscess. only one region of air in the pelvis of
the right TP kidney. no air or fluid around the kidney.
bilateral pleural effusions. otherwise, no acute path in
ab/pelvis.
CXR - No PTX, RIJ in appropriate position, atelectasis RLL with
some opacification, ? aspiration PNA
[**8-11**]: CT: 12mm collection of air in the transplant right pelvic
kidney pelvis, cannot exclude abscess. only one region of air in
the pelvis of the right TP kidney. no air or fluid around the
kidney. bilateral pleural effusions. otherwise, no acute path in
ab/pelvis.
[**8-11**]: U/S: PFI: There is indistinct corticomedullary
differentiation with elevated resistive indices in upper,
middle, and lower pole measuring up to 0.8. There is lack of
diastolic flow in the main renal artery. Overall, features are
concerning for worsening of the parenchymal process noted on the
prior examination. There are no perinephric collections. There
is no hydronephrosis. The bladder was collapsed
[**8-15**] CT Torso: jej and large bowel thickening, b/l extensive PNAs
and effusions
Brief Hospital Course:
The patient was admitted to the SICU already on pressor support
from OSH. She was intubated on arrival given her instability.
She received aggressive fluid resuscitation overnight on [**8-11**].
Infectious disease was consulted and remained involved on her
antibiotic regimen. Over the ensuing 18 hours from admission
she remained acidemic requiring vasopressors. It was determined
that conservative
management with fluids and antibiotics were not controlling her
infection and the decision was made to proceed with transplant
nephrectomy as a definitive procedure for infection source
control. She underwent the transplant nephrectomy on [**2177-8-12**]
without any acute events. Broad spectrum antibiotics were
continued. CVVH was initiated on [**8-12**]. She was unable to wean
from the vasopressor support initially, however after 24hrs she
gradually began to improve with a lessening pressor requirement.
Her UCx grew MDR E. Coli. Vascular surgery was consulted for
her left lower extremity chronic ischemia. Multipodus boots
were recommended but no acute intervention was required. An
outpatient angiogram will be performed to further assess. A
postpyloric dobhoff tube was placed for TF. She was extubated
on [**8-20**] and remained stable as oxygen therapy was weaned. A
tunnelled line for HD was placed by IR on [**8-21**]. She
transitioned from CVVH to HD on [**2177-8-21**]. Initial attempts at HD
resulted in hypotension so midodrine was started. She then
underwent successful HD with gradual fluid removal over the next
week and ensuing hospital stay. Her mental status gradually
improved. Speech and swallow was consulted and initally
recommended NPO however as her mental status improved she was
advanced to nectar liquids and purees, then to ground solids.
She was transferred to the floor on [**8-28**] where she gradually
improved. Tube feedings continued via the postpyloric feeding
tube. Speech and swallow evaluations gradually liberalized her
diet. She was initially at risk for aspiration, but improved to
advance to regular food and thin liquids. A PEG tube was placed
on [**2177-9-10**]. She tolerated this well and was kept npo x 24 hours.
Diet and tube feeds via the PEG were resumed. She tolerated this
well and the postop pyloric feeding tube was removed.
Blood sugars were difficult to control given multiple changes in
diet. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtain and insulin was adjusted with
increase of the Glargine and a Humalog sliding scale ordered.
PT worked with her extensively. She had developed plantar
flexion. Multipodis splints were utilized. By [**9-12**], she was able
to ambulate in the room with max assist. Please refer to
physical therapy notes.
A family meeting was done with the health care proxy noted as
her husband [**Name (NI) 37938**] with her sister [**Name (NI) 4115**] as back up proxy. The
patient declared that she wanted to have DNR status and a
comfort care form was sign.
Medications on Admission:
Procrit SQ twice a week, Bactrim 400-80', Cellcept [**Pager number **]", Prograf
3", Indur 30', Lantus 20U qAM, Levothyroxine 150', Metoprolol
50", Norvasc 10', Omeprazole 20', oxybutynin 3.9 mg', Paxil 20',
Lexapro 10', reglan 10 QID, NaHCO3 650', metamucil, loperamide
2.5'''
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Pager number **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Pager number **]:
2-4 Puffs Inhalation Q2H (every 2 hours) as needed for wheezy.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet, Chewable
PO DAILY (Daily).
5. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
9. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every
6 hours) for 3 days: stop after [**9-15**].
10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
11. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
12. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: Five (5)
ML PO Q4H (every 4 hours) as needed for pain.
14. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Twenty (20) units
Subcutaneous once a day.
15. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: follow sliding
scale Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Hospital1 1562**]
Discharge Diagnosis:
sepsis secondary to UTI
kidney transplant nephrectomy
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, increased abdominal pain, incision
redness/bleeding/drainage, malfunction of the tunnelled dialysis
line
continue Hemodialysis via the tunnelled line
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2177-9-24**] 12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2177-9-24**] 1:30
|
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51,462
| 137,668
|
20299
|
Discharge summary
|
report
|
Admission Date: [**2200-4-18**] Discharge Date: [**2200-5-10**]
Date of Birth: [**2142-10-12**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Cephalosporins
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Upper GI bleed.
Major Surgical or Invasive Procedure:
--Intubation
--EGD
--Mechanical ventilation
--TIPS placement
--IVC filter placement on [**4-30**]
History of Present Illness:
This is a very nice 57-year-old woman with hcv cirrhosis
(contracted from needle stick while working as a nurse)
refractory to anti-viral therapy, ascites, grade III esophageal
varices (s/p banding x3, [**2200-4-9**]), splenomegaly and portal
hypertensive gastropathy who is transferred to ET after a
hospital course complicated by 2 upper GI bleeds, TIPS
procedure, E.Coli bacteremia, and VAP.
Ms. [**Known lastname 54488**] was originally admitted to [**Hospital1 18**] on [**4-18**] after
vomiting up ~600ml of blood and having black stools. She
received octreotide and protonix and was transfused 4 units PRBC
and 1 unit FFP that night (with an additional 2 units transfused
over the subsequent 2 days.) She was intubated for EGD, which
showed grade III esophageal varices and an ulcerated oozing mass
at a prior
banding site in the distal esophagus; hemostasis was achieved.
Patient began spiking low grade fevers on second day of hospital
admission and she was treated with broad spectrum antibiotics
(initially vanc/zosyn-->vanc/tobramycin-->currently on
vanc/[**Last Name (un) 2830**]/levofloxacin). Patient was also found to have esbl
E.coli in her blood and will need to finish a 14-day-course of
meropenem.
She was stabilized after the initial bleed, extubated, and sent
to the floor. At that time she was started on Lovenox for
history of ATIII deficiency/DVTs and prednisone for a gout
flare. On [**4-23**], she started rebleeding (massive hemoptysis) on
the general medicine floor and a "code blue" was called.
Patient was urgently transferred to the MICU. A repeat EGD was
performed, but varices were not amenable to banding. IR was
then consulted who tried performing a TIPS on the night of [**4-23**],
but were unsuccessful. They tried again on [**4-24**] via a
percutaneous approach and succeeeded with TIPS and embolized
varicies. However, TIPS is still "high pressure" (higher than
the varices) and bleeding is still a possibility. On [**4-25**],
patient was weaned from the vent, but due to copious secretions,
her coverage was broadened to vanc/[**Last Name (un) 2830**]/levoflox as above.
Patient has been stable for the last 3-4 days. NG tube was
removed on [**4-28**] and PPI was switched to PO. She continues on
octreotide (due to high TIPS pressures) and Rifaxamin. IVC
filter was placed this AM in context of hypercoagulable state,
but needs to be removed once patient can tolerate
anti-coagulation.
On the floor, patient is awake, alert, and in no acute distress.
She complains of pain from gout in her left big toe.
Past Medical History:
Hepatitis C, dx [**2184**], genotype 1, multiple attempts at
ribavirin/interferon
Splenomegaly
Varices s/p banding x3
Biliary pancreatitis [**2193**] -> cholecystectomy
Rectal abscess
Uveitis
Gout
Mild pulmonary hypertension
Recurrent cellulitis/phlebitis
Bilateral DVT - on warfarin outpatient, d/c'ed in hospital
LLE MSSA abscess with fasciotomy/debridement, [**2194**]
LLE cellulitis, abscess (pan-sensitive pseudomonas), tx with
Zosyn, [**1-/2200**]
Social History:
Worked as nurse, then nurse administrator. Close to daughter.
Nonsmoker (quit [**2193**], 7 cigs/d x15y), little EtOH, no IVDU.
Family History:
Her mother had pancreatic cancer, and her father brain cancer
(NOS). There is no history of clots or phlebitis in the family,
to her knowledge.
Physical Exam:
On admission:
98.2 99/60, 70, 95% RA
General: Alert, oriented, no acute distress
Skin: Appears mildly jaundiced (patient reports baseline color);
left shin with left heal wound, no drainage
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Few crackles left base; otherwise clear to auscultation
bilaterally
CV: RRR, normal S1/S2, [**12-4**] early systolic murmurs LUSB
Abdomen: Normoactive bowel sounds; obese; soft, nontender; small
liver
Ext: Warm, well-perfused; 2+ DP and radial pulses, symmetric; no
lower extremity edema
On discarge:
98.2, 102/58, 64, 94% on RA
General: Alert, oriented, no acute distress
Heent: Mucous membranes moist
Chest: Clear to auscultation bilaterally; no wheezes, rales, or
rhonchi
Abdomen: +BS, obese, soft, non-tender, non-distended
Extremities: 1+ edema bilaterally, well-healed scar on left
shin
Skin: Warm, dry, slightly jaundiced
Pertinent Results:
Labs on Admission:
[**2200-4-18**] 03:30AM WBC-7.9 RBC-2.91* HGB-9.3* HCT-26.8* MCV-92
MCH-32.2*# MCHC-34.9# RDW-16.3*
[**2200-4-18**] 03:30AM NEUTS-80.4* LYMPHS-13.0* MONOS-4.6 EOS-1.8
BASOS-0.2
[**2200-4-18**] 03:30AM PLT COUNT-168
[**2200-4-18**] 03:30AM PT-14.9* PTT-28.3 INR(PT)-1.3*
[**2200-4-18**] 03:30AM ALT(SGPT)-17 AST(SGOT)-33 LD(LDH)-180 ALK
PHOS-46 TOT BILI-0.9
[**2200-4-18**] 03:30AM ALBUMIN-2.9*
[**2200-4-18**] 03:30AM GLUCOSE-111* UREA N-23* CREAT-0.9 SODIUM-140
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
Micro:
blood cx: [**2200-4-19**] [**12-31**] sets: E. coli: extended-spectrum
beta-lactamase (ESBL) producer and should be considered
resistant to all penicillins, cephalosporins, and aztreonam
sputum cx: [**2200-4-19**] gram stain: >25 PMNs and <10 epithelial
cells/100X field. 2+ (1-5 per 1000X FIELD):GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD):GRAM POSITIVE
ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Imaging:
EGD: [**4-18**]: Ulcerted mass with oozing at previous banding site
noted in the distal esophagus (injection). Mosaic appearance in
the stomach compatible with portal hypertensivegastropathy.
Blood clots noted in the fundus.
Blood noted in duodenum, no acitve bleeding. Varices at the
middle third of the esophagus and lower third of the esophagus.
Otherwise normal EGD to third part of the duodenum.
EGD [**4-23**]:
Esophageal varices. Blood in the stomach
Otherwise normal EGD to second part of the duodenum
Recommendations: Bleeding from large esophageal varix unable to
maintain hemostasis despite two well placed bands. IV PPI,
octreotide gtt, antibiotics. Urgent IR consultation for TIPS.
Intubation prior per IR.
TIPS [**4-24**]:
1. Successful TIPS placement and stenting of portal vein
stenosis using a 10 mm x 94 mm Wallstent and a 12mm x 60mm
Luminex stent. Both the stents were angioplastied to 10-mm
diameter.
2. Pressure measurements pre- and post-TIPS placement with
30-mmHg gradient before and 18 mmHg gradient after the TIPS
placement.
3. Successful embolization of large coronary vein varix using
absolute
alcohol and multiple coils.
4. Replacement of a triple-lumen central venous catheter9trauma
line) via
right internal jugular venous access with the tip of the
catheter terminating
in the SVC. The line is ready for use.
5. Repositioning of right arm PICC line with the tip of the
catheter
terminating in the SVC.
IVC filter placement:
1. Successful infrarenal placement retrieval of G2 IVC filter
via the right common femoral venous approach.
2. Normal IVC-gram with no duplications and no filling defects
noted.
CXR [**2200-5-2**]:
Moderate cardiomegaly is unchanged. Right PICC tip is in
unchanged position in the mid right subclavian vein. The lungs
are clear. If any, there is a small right pleural effusion.
Brief Hospital Course:
This is a very nice 57-year-old woman with a history of HCV
cirrhosis refractory to antiviral therapy complicated by
ascites, grade III esophageal varices (s/p banding x3 on
[**2200-4-9**]), splenomegaly, and portal hypertensive gastropathy now
with 2 recent UGI bleeds, TIPS procedure, e.coli bacteremia, and
VAP.
.
# GI BLEED: Ms. [**Known lastname 54488**] presented with an acute hematocrit drop
(26.8 from 30) in the context of multiple episodes of
hemetemesis and melena, concerning for variceal bleed. Upon
arrival to ED, patient was started empirically on IV protonix
gtt with bolus and octreotide gtt with bolus and transferred to
the ICU for emergent endoscopy. Ms. [**Known lastname 54488**] was intubated
peri-procedurally with possible aspiration event (see below) and
started on IV ciprofloxacin for SBP ppx. EGD showed ulcerated
mass at area of prior banding which was injected, presumed to be
source of bleed. EGD also showed portal hypertensive
gastropathy, blood clots in the fundus and nonbleeding varices
at the middle third of the esophagus and lower third of the
esophagus. Initially, patient remained hemodynamically stable
with Hct 29- 30 and was followed conservatively with serial Hct
every 4 hours. Patient was eventually transferred out of the
ICU, and monitored closely on the medical floor. She was
started on lovenox at that time (for anti-thrombin III
deficiency) and prednisone (for a gout flare); she rebled again
on [**4-23**] and and a "code blue" was called on the medicine floor.
She was transferred emergently back to the ICU where an
endoscopy showed bleeding from a large esophageal varix.
Hemostasis could not be achieved on EGD alone, and IR was called
for urgent TIPS placement. First TIPS placement failed however,
IR was able to place successful TIPS on [**4-24**]. As per most
recent abdominal ultrasound, TIPS is patent with good flow.
Patient was given multiple blood products and hemodynamic
stability was maintained. Ms. [**Known lastname 54489**] last bleed was on [**4-27**],
around the site of her NG tube. The tube was subsequently
removed, and patient has had no episodes of bleeding since. Her
hematocrit has remained fairly stable although she has required
a few transfusions for TIPS hemolysis (see below). Ms. [**Known lastname 54488**]
has close follow-up with GI on [**5-21**] for repeat EGD.
# ECOLI BACTEREMIA: On [**4-19**], patient developed low grade fever
to 100.7 with LLL consolidation seen on CXR. Blood, urine and
sputum cultures were obtained and patient was switched from
ciprofloxacin to Vanc/Zosyn/Cipro given concern for healthcare
associated PNA. Blood cultures returned with ESBL e.coli.
Arterial line discontinued at this time. ID was consulted and
antibiotics were switched to meropenem. Patient completed a 14
day course of meropenem for bacteremia on [**5-3**]. Her white count
remained stable; she eventually defervesced.
# VENTILATOR ASSOCIATED PNA: Following semielective intubation,
patient noted to have a new left lower lobe consolidation in the
setting of clinical concern for aspiration event. Initially
thought to be atelectasis given acuity of onset and preservation
of oxygenation. PEEP increased on mechanical ventilation
settings to allow re-expansion of lung parenchyma with minimal
results. Sputum culture grew Klebsiella. Following extubation,
patient was encouraged to use incentive spirometry. She was
covered with vancomycin, levofloxacin, and meropenem for an 8
day course, which finished on [**5-3**].
# ANTITHROMBIN III DEFICIENCY: Ms. [**Known lastname 54488**] has a history of
multiple DVTs and has been on chronic coumadin for
anti-coagulation. She has a reported history of ATIII
deficiency, although her antithrombin levels here are within
normal limits. Her coumadin likely contributed to the extent of
her bleed; after she stopped bleeding, she was started on
lovenox, though again had an upper GI. The decision was finally
made to place an IVC filter for a few weeks until varices
decompressed and patient could be safely systemically
anticoagulated. IVC was placed on [**4-30**], and should come out
within 6 weeks from that date. Ms. [**Known lastname 54488**] has follow-up with
GI for repeat EGD and then with hematology for likely
re-initiation of systemic anticoagulation.
# HEPATITIS C CIRRHOSIS: Suspected secondary to work exposure
as a nurse. Patient was discharged on lasix, spironolactone,
rifaxamin, lasix, lactulose, nadolol, and pantoprazole. MELD is
14 at discharge. Ms. [**Known lastname 54488**] will need outpatient evaluation
for consideration of liver transplant.
# GOUT: Patient had acute gout attack during her
hospitalization. She was started on prednisone after her first
GI bleed had abated however, she re-bled and the prednisone was
stopped. Ms. [**Known lastname 54488**] was started on colchicine with good
effect.
# DECONDITIONING: Ms. [**Known lastname 54488**] is extremely deconditioned from
this hospitalization. She will need to be encouraged to eat
healthy, nutritious meals (while maintaining a BMI <40) and to
engage in PT. She will also benefit from therapy and
psychological support.
Medications on Admission:
Lasix 100mg PO daily
Nadolol 20mg PO daily
Omeprazole 40mg PO daily
Spironolactone 50mg PO daily
Warfarin
Calcium carbonate
Magnesium
Allopurinol 300mg PO daily
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
cramping, gas.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime)
as needed for insomnia.
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Upper GI bleed
2. Gout
3. Bacteremia
4. Ventilator associated pneumonia
5. TIPS hemolysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 54488**],
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having an upper GI bleed.
Initially, you were admitted to the ICU; you had an edoscopy,
which showed bleeding ulcers at the site of a variceal bands.
The bleeding eventually stopped and you were treated
supportively. Subsequently, you were transferred to the general
medicine floor where you again had an upper GI bleed; you were
transferred back to the ICU, where a TIPS was placed. Your
course was also complicated by ventilator associated pneumonia
and bacteremia. You have required multiple blood products
during this hospitalization.
.
The following are your discharge medications:
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
.
Return to the hospital if you develop bleeding from your mouth
or rectum, fever, chills, light-headedness, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
yellowing of the skin or eyes, or any other concerning signs or
symptoms.
Followup Instructions:
(Hepatology appointment and Endoscopy)
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2200-5-21**] 9:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2200-5-21**] 9:00
(Hematology)
Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2200-5-23**]
11:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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[
"44.43",
"42.33",
"38.7",
"39.79",
"38.93",
"96.71",
"39.1",
"87.51",
"45.13",
"38.91",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14280, 14351
|
7604, 12791
|
301, 400
|
14501, 14501
|
4731, 4736
|
15796, 16338
|
3632, 3778
|
15410, 15773
|
14372, 14480
|
12817, 12979
|
14683, 15386
|
3793, 3793
|
246, 263
|
428, 2993
|
4750, 7581
|
14516, 14659
|
3015, 3470
|
3486, 3616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,387
| 143,551
|
46499
|
Discharge summary
|
report
|
Admission Date: [**2175-11-30**] Discharge Date: [**2175-12-2**]
Date of Birth: [**2103-2-12**] Sex: F
Service: NEUROLOGY
Allergies:
Lisinopril / Plavix
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
IV-tPA
History of Present Illness:
Ms. [**Known lastname **] is a 72 yo left handed woman with a history of PVD,
diabetes, hypertension and hyperlipidemia who presents this
morning following sudden onset left sided weakness. The patient
reports she felt well this morning, better than she has in
months. She was in her kitchen at around 9am when she suddenly
fell to the ground and found her left side to be weak. She
denies hitting her head and states she basically just slumped on
to her backside without any injury. EMS was called and she was
brought to [**Hospital1 18**].
Upon arrival, a code stroke was called. Initial evaluation
revealed left sided weakness, sensory neglect, right gaze
preference and dysarthria. CT of the head was without evidence
of bleed or mass; CTA and CT perfusion were suggestive of a
right
MCA occlusion. The risks and benefits where discussed and the
decision to give tPA was made.
Currently, the patient denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denied difficulties
producing or comprehending speech. She reports weakness of the
left side and notes her left hand is numb. She denies bowel or
bladder incontinence or retention. Denied difficulty with gait.
On general review of systems, the patient denied recent fever or
chills. 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.
Past Medical History:
-HTN
-Hyperlipidemia (HDL 50s and LDL 50s-70s on simvastatin 40)
-Heavy chronic smoking history
-Type II Diabetes (recent A1cs are in good range 6-7% on home
metformin monotherapy after weight loss of 40lbs last year)
-Chronic left great toenail fungus/removal nail bed [**2-5**]
-s/p toe amputation [**4-5**] (necrotic), c/b popliteal DVT (was Tx
with Warfarin A/C until suffering a LGIB (Hgb 5) in [**9-5**], polyps
removed, Hgb stable at 9-10 since [**2175-9-25**])
-Appendectomy
-Tonsillectomy
Social History:
[**1-28**] ppd cigarettes, formerly 3/4-1ppd for 50 years (tried
quitting with patch, Chantix, cold [**Country 1073**], all without success;
never tried nicotine inhalers).
Denies IVDU and ETOH.
She lives in [**Location 86**] with her husband, [**Name (NI) **], who suffers from
dementia. She is a retired receptionist.
Family History:
One sister, age 66, with diabetes. One brother with diabetes.
Physical Exam:
On initial presentation to the ED:
Temp:97.6 HR:98 BP:117.62 Resp:18 O(2)Sat:98% Guaiac negative
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx ******* a hematoma
over the left temple near the orbit was noted to be forming
during this exam, pressure was applied.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, normal s1/s2. No murmurs,
rubs,
or gallops appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 2+ radial pulsed. Left great toe amputated
Skin: no rashes, bandaged cut on the left anterior foot, 2nd toe
with necrotic ulcer.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
initially dysarthric but this improved over the course of the
formal exam. The pt. had good knowledge of current events.
There
was no evidence of apraxia. There was a right sided gaze
preference but no clear visual neglect, calculations intact.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and minimally reactive. Visual fields full
on
bedside confrontation testing. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Mild partial left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone in the LE bilaterally.
Initial left pronator drift but able to sustain antigravity x 5
second. No rigidity. No adventitious movements, such as
tremors,
noted. No asterixis.
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 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
(formal strength testing conducted post imaging and tPA)
-Sensory: Does not appreciate light touch or vibratory sense on
the left arm and leg, but reports feeling pinprick, cold
sensation. Right sided sensation intact. Diminished
proprioception to the knees bilaterally. Extinction to double
simultaneous stimuli on the left.
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 0 0
R 3 3 3 0 0
Plantar response was extensor on the right, but the left was
amputated
-Coordination: Initially clearly ataxic on left on FNF but this
improved on repeat exam. Mild action tremor bilaterally.
-Gait: Deferred
Pertinent Results:
[**2175-12-1**] 01:25AM BLOOD Triglyc-147 HDL-56 CHOL/HD-3.0 LDLcalc-83
[**2175-11-30**] 11:09AM BLOOD %HbA1c-6.8* eAG-148*
[**2175-12-2**] 07:35AM BLOOD Albumin-4.4 Calcium-9.5 Phos-4.6* Mg-1.5*
[**2175-12-2**] 07:35AM BLOOD Glucose-189* UreaN-18 Creat-0.6 Na-137
K-4.8 Cl-99 HCO3-25 AnGap-18
[**2175-12-2**] 07:35AM BLOOD ALT-11 AST-16 AlkPhos-52 TotBili-0.3
[**2175-12-1**] 01:25AM BLOOD cTropnT-0.01
[**2175-12-2**] 07:35AM BLOOD PT-12.8 PTT-35.0 INR(PT)-1.1
[**2175-11-30**] 09:30AM BLOOD PT-13.0 PTT-34.0 INR(PT)-1.1
[**2175-12-2**] 07:35AM BLOOD WBC-8.6 RBC-4.40 Hgb-9.7* Hct-30.2*
MCV-69* MCH-22.0* MCHC-31.9 RDW-17.9* Plt Ct-377
[**2175-12-1**] 01:25AM BLOOD WBC-9.2 RBC-4.46 Hgb-9.7* Hct-30.5*
MCV-69* MCH-21.7* MCHC-31.7 RDW-18.3* Plt Ct-332
[**2175-11-30**] 09:30AM BLOOD WBC-7.3 RBC-4.80 Hgb-10.4* Hct-33.5*
MCV-70* MCH-21.6* MCHC-31.0 RDW-18.0* Plt Ct-358
[**2175-11-30**] 12:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2175-11-30**] 10:05AM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
NCHCT / CTA / CT-perfusion on presentation at ED [**11-30**]:
1. Right middle cerebral artery inferior division infarction.
2. Bilateral atherosclerosis involving the origin of the
internal carotid
arteries with 70% of stenosis on the left and 40% stenosis on
the right.
3. Enlarged left thyroid lobe with multiple hypodensities. If
further
evaluation is desired, dedicated ultrasound can be performed.
MRI/MRA brain 11/4-5:
FINDINGS: There is no intracranial hemorrhage. There is slow
diffusion
involving the right parietal and right insular cortex and right
external
capsule in keeping with acute infarct. There is no intracranial
mass, mass
effect or shift of midline structures. There is slight asymmetry
of the
lateral ventricles. There is a background of mild
microangiopathic small
vessel disease involving the subcortical and deep white matter
and brainstem.
IMPRESSION: Acute infarct in the right MCA distribution.No
hemorrhage or mass effect.
NCHCT at 24h post-tPA on [**12-1**]:
IMPRESSION:
1. Subtle hypodensity along the right insula and right frontal
lobe,
corresponds to evolving right middle cerebral artery infarction.
2. No evidence of acute hemorrhage.
TTE [**11-30**]:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. with borderline normal free wall
function. The aortic valve is not well seen. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**1-28**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2175-2-9**], the left ventricular ejection fraction is
somewhat lower. Severe pulmonary hypertension is now measured,
but the technically suboptimal nature of both studies precludes
definitive comparison.
Brief Hospital Course:
Mrs. [**Known lastname 40946**] responded well to IV-tPA given in the ED within
one hour of the onset of her stroke symptoms, as detailed above.
MRI (DWI/ADC imaging) confirmed a small acute infarcted
territory in the Right-MCA (inferior M2 division) distribution.
This territory involved the lateral post-central gyrus and the
Right posterior insular cortex (also seen as hypodense cortex on
the 24h follow-up NCHCT, which confirmed that there was no
intracerebral hemorrhage after tPA administration). Her H&H were
stable. She had a small bruise on the left side of her head and
a raccoon-eye hematoma on the left, presumably from falling at
the onset of her stroke Sx, which remained stable after tPA. She
cleared her Speech and Swallow and Physical Therapy evaluations
with flying colors. TTE was negative for vegetation or thrombus.
We did not get a TEE due to her refusal to take warfarin even if
postitive. Right carotid had 40% stenosis (left 70%). Given the
location of her stroke, involving the right insula, we were
concerned for autonomic/cardiac complications, but her ECG was
unconcerning for new ischemic changes and her telemetry
monitoring did not reveal any concerning rhythms over >48h and
her troponin-Is were negative times two.
She has minimal remaining stroke symptoms, including decreased
sensation to light touch and pinprick on the left (possibly with
a component of left sensory neglect) as well as diminished
joint-position sense. [**Last Name **] problem with
fluency/repetition/[**Location (un) 1131**]/speech. A little lisp, but no
dysarthria. No weakness detectable on exam.
Her FLP was notable for a good HDL of 50 and LDL of 83, slightly
above goal (less than 70 for diabetic pt), so her simvastatin
was increased from 40mg to 80mg. She was started on Aggrenox for
antiplatelet therapy for prevention of stroke recurrence (she
has a documented Plavix allergy, rash). She was counseled by Dr.
[**Last Name (STitle) 54849**] of Neurology regarding smoking cessation to prevent
further vascular diseases including stroke, MI, PAD. She was
sent home with a prescrition for nicotine inhalers to replace
cigarettes if she desires.
She will call her outpatient PCP and Dr.[**Name (NI) 17720**] office for
follow-up [**Name (NI) 4314**] ASAP and in 4-8weeks, respectively.
Medications on Admission:
ALBUTEROL SULFATE 90 mcg - 2 puffs q 4-6 h prn
ATENOLOL - 25 mg Tablet - one Tablet(s) by mouth once daily
DULOXETINE [CYMBALTA] 1 Capsule(s) by mouth twice a day
FLUTICASONE 110 mcg/Actuation Aerosol - 2 puffs [**Hospital1 **]
HYDROCHLOROTHIAZIDE - 25 mg daily
LATANOPROST 0.005 % Drops OU Daily
METFORMIN - 1000mg [**Hospital1 **] + 500mg daily
OMEPRAZOLE - 40 mg Capsule DAILY
SIMVASTATIN - 40 mg Tablet DAILY
VALSARTAN [DIOVAN] - 80 mg [**Hospital1 **]
ASPIRIN - 81 mg DAILY
OMEGA-3 FATTY ACIDS 1,200 mg-144 mg Capsule - [**Hospital1 **]
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*0 0* Refills:*0*
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
5. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day) as needed for stroke.
Disp:*60 Cap(s)* Refills:*2*
8. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for stroke, DM; LDL [**11-30**] was 83 (>70): this is an
increase in your dose from 40mg previously because your LDL
cholesterol was 83, which is greater than 70, which it should be
below because you have diabetes.
Disp:*60 Tablet(s)* Refills:*2*
9. nicotine 10 mg Cartridge Sig: One (1) cartridge Inhalation
q1h as needed for nicotine cravings: Please use this to replace
cigarrette smoking.
Disp:*168 cartridges (one package)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Stroke, Right inferior MCA (M2) s/p IV-tPA with significant
improvement.
Discharge Condition:
AOx3. Full power in all muscles/extremities. No more major
hemisensory deficits or extinction to DSS (seems to be back to
baseline). Mild dysmetria on Left on FNF. Afebrile/HDS/VSS. Gait
normal and steady.
Discharge Instructions:
You were brought to the hospital for a stroke on the Right side
of your brain. You were given a powerful blood-thinning
medication called t-PA. Your stroke symptoms were greatly
reduced shortly after the medication began, and your residual
symptoms are a slight sensory change on the left side of your
body.
Followup Instructions:
Call your PCP for [**Name9 (PRE) 702**] appointment ASAP.
Please call the Vascular (stroke) [**Hospital 878**] Clinic for an
appointment in 4-8weeks. Please call ASAP:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2175-12-2**]
|
[
"434.91",
"272.4",
"440.20",
"342.90",
"250.70",
"496",
"V49.72",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
13398, 13404
|
9272, 11576
|
302, 311
|
13521, 13729
|
5865, 9249
|
14085, 14507
|
2750, 2813
|
12169, 13375
|
13425, 13500
|
11602, 12146
|
13753, 14062
|
4205, 5846
|
2828, 3631
|
243, 264
|
339, 1874
|
3646, 4188
|
1896, 2396
|
2412, 2734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,131
| 147,005
|
37569
|
Discharge summary
|
report
|
Admission Date: [**2120-2-9**] Discharge Date: [**2120-2-21**]
Date of Birth: [**2067-4-11**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Pedestrians struck
Major Surgical or Invasive Procedure:
[**2120-2-12**]: ORIF Right tibial plateau fracture, ORIF left humeral
shaft fracture. Closed treatment of left clavicle and left
scapula fracture
History of Present Illness:
Mr. [**Known lastname 84326**] is a 52 year old man who was a pedestrian struck at
moderate speed by car - pt denies LOC. Per EMS - car w/
significant damage. He has c/o left upper extremity pain, left
knee pain. He was transported to the [**Hospital1 18**] for further care
Past Medical History:
1. HIV
Social History:
Lives with wife in an apartment on the [**Location (un) 470**]
Works at a hotel and as a cab driver
Family History:
n/a
Physical Exam:
TEMP HR BP RR
Constitutional: uncomfortable
Head / Eyes: Pupils equal, round and reactive
to light,
Extraocular muscles intact,
forehead abrasion
ENT / Neck: Oropharynx within normal limits
Chest/Resp: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal
first and
second heart sounds
GI / Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle
tenderness
Musc/Extr/Back: No cyanosis, clubbing or edema,
left proximal
humerus with tenderness,
deformity, decreased ROM [**3-12**]
pain.
Bilateral knee abrasions
Skin: No rash, Warm and dry
By [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**].
Pertinent Results:
[**2120-2-9**] 02:10AM WBC-9.1 RBC-4.03* HGB-12.6* HCT-39.4* MCV-98
MCH-31.3 MCHC-32.1 RDW-13.9
[**2120-2-9**] 02:10AM PLT COUNT-194
[**2120-2-9**] 02:26AM GLUCOSE-135* LACTATE-2.9* NA+-141 K+-3.5
CL--103 TCO2-23
[**2120-2-9**] 02:10AM UREA N-9 CREAT-1.2
[**2120-2-9**] CT C Spine : No acute fracture or malalignment.
[**2120-2-9**] Head CT : No acute intracranial abnormality.
[**2120-2-9**] CT Chest/Abd/Pelvis :
1. No acute intra-abdominal or pelvic injury.
2. Possible atelectasis versus very small pulmonary contusion or
hemorrhage at the left lung apex. However, these findings may
represent volume averaging and given the small size of the
opaciy, are of doubtful significance.
3. Multiple fractures involving the left scapula, humerus and
clavicle.
Please see dedicated left upper extremity radiographs for better
evaluation of the humeral fracture.
4. Equivocal non-displaced left posterior 3rd through 6th rib
fractures.
5. Cholelithiasis.
[**2120-2-9**] Right hip/knee :
1. Comminuted right lateral tibial plateau fracture with
extension to the
articular surface.
2. No pelvic or hip fracture.
[**2120-2-9**] Left shoulder/arm : 1. Comminuted left clavicular
fracture with normal AC and coracoclavicular intervals.
2. Scapular fracture, better evaluated on concurrent CT torso.
3. Left mid humerus fracture.
[**2120-2-10**] CXR : No interval change. No evidence of pulmonary
contusions.
Brief Hospital Course:
Mr. [**Known lastname 84326**] presented to the [**Hospital1 18**] on [**2120-2-9**] after being a
pedestrian struck. He was evaluated by the trauma and
orthopaedic surgery service and found to have a left clavicle
fracture, left scapular body fracture, left humeral shaft
fracture, right tibial plateau fracture, left apex pulm
contusion, and left posterior rib [**4-13**] fractures. He was
admitted to the Trauma ICU, consented, and prepped for surgery.
On [**2120-2-11**] he was transferred from the Trauma ICU to the floor.
On [**2120-2-12**] he was taken to the operating room and underwent an
ORIF of his left humeral shaft fracture and right tibial plateau
fracture. Also on [**2120-2-12**] he was transfused with 1 unit of
packed red blood cells due to acute blood loss anemia. He was
also seen sleep medicine due to OSA requiring CPAP
postoperatively. On [**2120-2-13**] he was again transfused with 1 unit
of packed red blood cells due to acute blood loss anemia. He
was seen by physical and occupational therapy to improve his
strength, mobility, and function. Infectious Disease was
consulted to evaluate his post operative fever. Neurology was
consulted foe to right sided facial weakness/asymmetry on
[**2120-2-16**]. His CT/MRI shows no process, and per patient report
that is has been commented on before for many years. There is
not acute workup needed. The rest of his hospital stay was
uneventful with his lab data and vital signs within normal
limits and his pain controlled. He is being discharged today in
stable condition.
Medications on Admission:
1. Truvada 1 tab. PO Daily
2. Ritonavir 100 mg PO Daily
3. Atazanavir 300 mg PO Daily
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: Two (2) Tablet
PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: [**2-10**] Subcutaneous DAILY
(Daily) for 4 weeks.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis
S/P pedestrian struck by car
1. Left humerus fracture
2. Left scapula fracture
3. Left clavicle fracture
4. Left posterior rib fractures [**4-13**]
5. Left apical pulmonary contusion
6. Right tibial plateau fracture
7. Acute blood loss anemia
Secondary diagnosis
1. HIV
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Discharge Instructions:
Continue to be touchdown weight bearing on your right leg with
your brace. Continue to be WBAT on your left arm, no heavy
lifting, and orthoplast splint only when up ambulating
Please take all medication as instructed
Lovenox for 4 weeks after surgery
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
[**Doctor Last Name **] brace: Unlocked, may come off for daily care
Left upper extremity: Elevate as much as possible, ice prn.
WBAT for ambulation, but no heavy lifting. use forearm crutch
(clavicle fx). Arm brace only when ambulating. ROM
shoulder/elbow/wrist twice daily
Treatment Frequency:
Staples out 14 days after surgery ([**2120-2-26**])
Dry dressing as needed for drainage or comfort
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 42773**] as you
need a sleep study as an outpatient to work up if you have sleep
apnea and for HIV follow up
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2120-2-21**]
|
[
"518.0",
"285.1",
"812.21",
"861.21",
"807.04",
"910.0",
"E814.7",
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"574.20",
"823.00",
"810.00",
"V08",
"351.8",
"327.23",
"821.21",
"916.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"93.90",
"79.31",
"99.04",
"79.09",
"79.05",
"78.07"
] |
icd9pcs
|
[
[
[]
]
] |
6216, 6289
|
3433, 4993
|
338, 488
|
6620, 6620
|
1991, 3410
|
7673, 8249
|
956, 961
|
5129, 6193
|
6310, 6599
|
5019, 5106
|
6723, 7146
|
976, 1972
|
7164, 7528
|
280, 300
|
516, 793
|
6634, 6699
|
7549, 7650
|
815, 823
|
839, 940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,661
| 179,475
|
47936
|
Discharge summary
|
report
|
Admission Date: [**2115-4-16**] Discharge Date: [**2115-4-24**]
Date of Birth: [**2040-9-12**] Sex: M
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
man, with a long history of chronic obstructive pulmonary
disease and a former smoking history. In the Fall of [**2113**],
he developed evidence of pneumonia in the right upper lobe,
treated with antibiotics. His symptoms resolved, but the
lesion in the right upper lobe persisted. CT scans suggested
malignancy, and operation was advised.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease with previous coronary bypass.
A preoperative PET scan was consistent with malignant process
without signs of metastasis.
HOSPITAL COURSE: On the day of admission, I performed a
bronchoscopy followed by a right upper lobectomy and
mediastinal lymph node dissection. Operation went well. The
patient was extubated in the operating room. He had a small,
persistent air leak, but his chest tubes were able to be
removed on the fourth postoperative day. He completed
rehabilitation and was discharged on the fifth postoperative
day on his usual medications and pain medication. Follow-up
in the Thoracic Oncology Center was arranged.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern4) 36759**]
MEDQUIST36
D: [**2115-8-2**] 12:05
T: [**2115-8-5**] 15:07
JOB#: [**Job Number 101146**]
|
[
"518.0",
"427.31",
"492.8",
"519.1",
"V45.81",
"788.20",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.3",
"40.29",
"38.91",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
780, 1556
|
174, 547
|
569, 762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,452
| 177,781
|
13308+56442
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-12-2**] Discharge Date: [**2133-12-9**]
Date of Birth: [**2055-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Chicken Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
scapular discomfort with associated dyspnea
Major Surgical or Invasive Procedure:
[**2133-12-4**] CABG x2 (LIMA to LAD, SVG to OM 1)
History of Present Illness:
78 year old male with known history of
hypertension presents to OSH complaining of discomfort in his
scapular area and associated dyspnea for approximately 48 hours.
He denies substernal chest pain and denies radiation of scapular
discomfort.Cardiac workup at OSH revealed new rapid atrial
fibrillation and coronary cath showed multivessel coronary
artery
disease. He was transferred to [**Hospital1 18**] for cardiac surgery
evaluation of coronary artery revascularization.
Of note he just completed a Z-pack for bronchitis 3 weeks ago.
Pt
states he has chronic bronchitis. Denies cough or shortness of
breath at admission.
Past Medical History:
new onset atrial fibrillation
hypertension, Gout, chronic back pain,
nocturnal SOB, chronic bronchitis
Social History:
Lives with:wife
Contact: Phone #
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx: quit 23yo. [**2-5**] PPD x 35y
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-9**] drinks/week [x] >8 drinks/week []
last glass of wine was Sun [**2133-11-29**]
Family History:
Father :74 died of CHF, c/b CVA Mother -no cardiac dz
Physical Exam:
Pulse:77 Resp: 20 O2 sat: 99% on 2Lpm nc
B/P Righ151/86
Height: 70" Weight:214 #
General:
Skin: Warm [x] Dry [x] intact [x]
HEENT: NCAT [x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] JVD []
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 [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right:2+ Left:2+
Carotid Bruit-none Right: Left:
Pertinent Results:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. There are filamentous
strands on the aortic leaflets consistent with Lambl's
excresences (normal variant). There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results at time of surgery.
POST-BYPASS: The patient is A paced. The patient is on no
inotropes. Biventricular function is unchanged. Mild (1+) aortic
regurgitation is seen. Mitral regurgitation is unchanged. The
aorta is intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
[**2133-12-8**] 09:40AM BLOOD WBC-12.0* RBC-3.39* Hgb-10.5* Hct-31.3*
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.7 Plt Ct-453*
[**2133-12-8**] 09:40AM BLOOD PT-12.5 INR(PT)-1.2*
[**2133-12-8**] 09:40AM BLOOD Glucose-152* UreaN-32* Creat-1.5* Na-141
K-4.0 Cl-101 HCO3-31 AnGap-13
[**2133-12-3**] 02:24AM BLOOD ALT-20 AST-23 LD(LDH)-148 AlkPhos-43
Amylase-60 TotBili-0.5
[**2133-12-3**] 02:24AM BLOOD Lipase-33
[**2133-12-3**] 02:24AM BLOOD %HbA1c-5.3 eAG-105
[**2133-12-3**] 02:24AM BLOOD %HbA1c-5.3 eAG-105
[**2133-12-9**] 05:47AM BLOOD WBC-8.0 RBC-3.14* Hgb-9.6* Hct-28.9*
MCV-92 MCH-30.7 MCHC-33.4 RDW-13.9 Plt Ct-434
[**2133-12-9**] 05:47AM BLOOD PT-12.7* INR(PT)-1.2*
Brief Hospital Course:
Admitted from OSH [**12-2**] and pre-op w/u completed. Remained on IV
NTG and IV heparin for pre-op A Fib. Underwent surgery with Dr.
[**Last Name (STitle) **] on [**12-4**] and was transferred to the CVICU in stbale
condition on titrated phenylephrine and propofol drips.
Extubated that evening and was transfered to the floor on POD #1
to begin increasing his activity level. Chest tubes and pacing
wires removed per protocol. Gently diuresed toward his pre-op
weight and beta blockade titrated. Went into A Fib again on POD
#2 and was started on amiodarone. Coumadin was also started on
POD #4. Target INR is 2.0-2.5 for A Fib.First INR check tomorrow
with results to PCP [**Name Initial (PRE) 40510**]. Converted to SR and was cleared
for discharge to home with VNA on POD #5. BUN/ creatinine check
tomorrow with results to cardsiac surgery office. All f/u appts
were advised.
Medications on Admission:
HCTZ 12.5 mg daily
Atenolol 25 mg daily
Aspirin 81 daily
Allopurinol ?mg daily -pt thinks its 50mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
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:*1*
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever .
Disp:*50 Tablet(s)* Refills:*0*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: through [**12-13**]; then 200 mg [**Hospital1 **]
[**Date range (1) 40511**];then 200 mg daily ongoing.
Disp:*80 Tablet(s)* Refills:*1*
8. Outpatient Lab Work
please draw BUN/creatinine Thurs [**12-10**] with results to cardiac
surgery office [**Telephone/Fax (1) 170**]
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 5 days.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
12. warfarin 1 mg Tablet Sig: daily dosing per Dr. [**Last Name (STitle) 40510**]
Tablet PO Once Daily at 4 PM: dosing today only [**12-9**] is 3 mg;
all further daily dosing per Dr. [**Last Name (STitle) 40510**].
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 40512**] Health Care
Discharge Diagnosis:
coronary artery disease s/p cabg x2
atrial fibrillation
hypertension, Gout, chronic back pain,
nocturnal SOB, chronic bronchitis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema .............
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw Thurs [**12-10**]
Results to Dr. [**Last Name (STitle) 40510**] phone [**Telephone/Fax (1) 40513**] or fax [**Telephone/Fax (1) 40514**]
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] Wed [**1-6**] at 1:45pm
Cardiologist:Dr. [**Last Name (STitle) 4922**] on [**1-7**] at 3:00pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Thurs [**1-14**] @ 10:30 AM , [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] 7
Wound check Nurse: [**Hospital Ward Name **] , [**Hospital Unit Name **] on [**12-17**] at 10:45am
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 40510**] in [**4-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw Thurs [**12-10**]
Results to Dr. [**Last Name (STitle) 40510**] phone [**Telephone/Fax (1) 40513**] or fax [**Telephone/Fax (1) 40514**]
*** please draw BUN/creatinine on Thursday [**12-10**] with results to
cardiac surgery office [**Telephone/Fax (1) 170**]
Completed by:[**2133-12-9**] Name: [**Known lastname 7280**],[**Known firstname **] Unit No: [**Numeric Identifier 7281**]
Admission Date: [**2133-12-2**] Discharge Date: [**2133-12-9**]
Date of Birth: [**2055-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Chicken Derived
Attending:[**First Name3 (LF) 741**]
Addendum:
Cardiologist appointment: Dr. [**Last Name (STitle) 7282**] on [**1-7**] at 3:00pm
Cardiologist: Dr. [**First Name8 (NamePattern2) 1221**] [**Name (STitle) 7283**] Thurs [**1-14**] @ 10:30 AM , [**Hospital Ward Name 7284**] [**Hospital Ward Name **] 7 cancelled
Discharge Disposition:
Home With Service
Facility:
[**Hospital 7285**] Health Care
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2133-12-9**]
|
[
"401.9",
"414.01",
"491.9",
"427.31",
"274.9",
"338.29",
"724.5",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10657, 10842
|
4463, 5345
|
339, 392
|
7522, 7764
|
2210, 4440
|
8908, 10634
|
1472, 1529
|
5501, 7263
|
7370, 7501
|
5371, 5478
|
7788, 8885
|
1544, 2191
|
256, 301
|
420, 1047
|
1069, 1174
|
1190, 1456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,716
| 175,801
|
5727
|
Discharge summary
|
report
|
Admission Date: [**2173-12-14**] Discharge Date: [**2173-12-17**]
Date of Birth: [**2147-4-25**] Sex: F
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: This is a 26-year-old female
with a known atrial septal defect with a prior transient
ischemic attack.
PHYSICAL EXAMINATION: Cardiovascular: Systolic flow murmur.
Chest: Clear to auscultation bilaterally. Abdomen: Benign.
Extremities are warm and well perfused. Neurologic: Grossly
intact. Pulses: 2+ right and left femorals, dorsalis pedis,
posterior tibial pulses, and radial.
HOSPITAL COURSE: The patient was brought to the operating
room on [**2173-12-14**], where an atrioseptal defect repair
was performed and an intraoperative transesophageal
echocardiogram was performed which showed the interatrial
septum was aneurysmal with a left-to-right shunt.
The patient's postoperative course was uneventful, and she
was transferred to the SCICU, and monitored closely. The
following postoperative day, she was transferred to the floor
where she remained in normal sinus rhythm.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Status post atrioseptal defect repair.
DISCHARGE MEDICATIONS: The patient will be continued on her
Coumadin.
FO[**Last Name (STitle) **]P PLAN: The patient is to followup with Dr. [**Last Name (Prefixes) 411**] in four months. The patient is to followup with Dr.
[**Last Name (STitle) 9006**], her primary care physician next week.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (STitle) 22843**]
MEDQUIST36
D: [**2173-12-16**] 21:52
T: [**2173-12-21**] 07:37
JOB#: [**Job Number 22844**]
|
[
"435.9",
"300.00",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.71",
"88.72",
"39.61",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
1151, 1191
|
1215, 1749
|
582, 1068
|
301, 564
|
174, 278
|
1093, 1129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,500
| 103,218
|
41205
|
Discharge summary
|
report
|
Admission Date: [**2125-1-22**] Discharge Date: [**2125-1-29**]
Date of Birth: [**2098-6-30**] Sex: F
Service: MEDICINE
Allergies:
Famotidine
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Acetaminophen intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 26 year old female with history of anxiety,
depression and multiple past suicide attempts who is transferred
to [**Hospital1 18**] from the OSH for the management of the acetaminophen
overdose. Per report, patient ingested approximately 7.5g of
acetaminophen in a suicude attempt on [**1-19**]. Patient presented to
the [**Hospital3 **] ED on [**1-20**] with acetaminophen level of 132. She
received 20 hour course of IV n-acetylcysteine. The 16-hr
component of the infusion was repeated due to evolving liver
failure. Her AST and ALT levels were 4500 and 7400,
respectively, with INR 1.8. She was transferred to [**Hospital1 18**] for
further management.
On presentation at [**Hospital1 18**], patient was in no distress. She had no
specific complaints except headache. She denied any nausea,
vomiting, abdominal pain, diarrhea, fever, chills, confusion.
Past Medical History:
-Hypothyroidism: on levothyroxine
-Amenorrhea secondary to low body weight: s/p recent 10-day
course of medroxyprogesterone 10 mg po daily to stimulate
ovulation ([**Date range (1) 89743**]), not successful
Past Psychiatric History:
-Depression with chronic thoughts of suicidality and self-harm:
history of prior suicide attempt at age 16 via Tylenol overdose.
Two prior hospitalizations at age 16 for Tylenol overdose and at
age 20 in context of severe SI.
-Anorexia: diagnosed at age 12, no prior hospitalizations
related to anorexia, currently with stable weight, working with
new nutritionist.
Social History:
Lives with parents, grandmother and older sister in [**Name (NI) 38**],
middle of 3 girls. Graduated [**Doctor Last Name **] undergrad and grad school
LCSW. Recently working as social worker at [**Hospital3 **] Mental
Health. She has a few friends, does not date. Exercise
'fanatic'. No known hx of abuse or trauma.
Family History:
Paternal grandmother and father with depression, both sisters on
antidepressants.
Physical Exam:
VS: 100.8 54 114/65 16 100% RA
Gen: NAD, sad affect, appropriate
Neuro: no focal deficit, no aterixis
HEENT: No icterus, oropharynx moist, without exudate, no LAD, no
thyromegaly
CV: RRR, S1S2, no mur
pulm: CTA b/l
abdom: soft, ND/NT, + BS, no hepatomegaly
extremities: no edema, no cyanosis, well perfused
Pertinent Results:
ADMISSION LABS
[**2125-1-22**] 06:50PM PT-20.1* PTT-36.0* INR(PT)-1.8*
[**2125-1-22**] 06:50PM PLT COUNT-112*
[**2125-1-22**] 06:50PM NEUTS-78.6* LYMPHS-15.8* MONOS-1.9* EOS-3.4
BASOS-0.3
[**2125-1-22**] 06:50PM WBC-5.0 RBC-3.54* HGB-12.2 HCT-33.8* MCV-96
MCH-34.5* MCHC-36.1* RDW-13.3
[**2125-1-22**] 06:50PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.0*#
MAGNESIUM-1.8 IRON-25*
[**2125-1-22**] 06:50PM LIPASE-23 GGT-37*
[**2125-1-22**] 06:50PM ALT(SGPT)-6860* AST(SGOT)-4114* LD(LDH)-2390*
ALK PHOS-65 AMYLASE-41 TOT BILI-0.7
[**2125-1-22**] 07:28PM LACTATE-1.3
[**2125-1-22**] 07:28PM TYPE-ART PO2-42* PCO2-36 PH-7.42 TOTAL CO2-24
BASE XS-0
.
DISCHARGE and PERTINENT LABS
[**2125-1-27**] 04:50AM BLOOD WBC-4.0 RBC-3.44* Hgb-11.8* Hct-33.1*
MCV-96 MCH-34.1* MCHC-35.6* RDW-13.2 Plt Ct-259
[**2125-1-27**] 04:50AM BLOOD Gran Ct-1780*
[**2125-1-27**] 04:50AM BLOOD ALT-[**2079**]* AST-104* AlkPhos-76 TotBili-0.2
[**2125-1-27**] 04:50AM BLOOD Albumin-3.7 Calcium-8.9 Phos-4.5 Mg-2.2
[**2125-1-26**] 04:35AM BLOOD WBC-2.7* RBC-3.45* Hgb-11.7* Hct-33.1*
MCV-96 MCH-33.7* MCHC-35.2* RDW-13.0 Plt Ct-201
[**2125-1-26**] 04:35AM BLOOD Neuts-35* Bands-0 Lymphs-51* Monos-5
Eos-7* Baso-2 Atyps-0 Metas-0 Myelos-0
[**2125-1-25**] 06:59AM BLOOD Fibrino-329
[**2125-1-25**] 06:59AM BLOOD VitB12->[**2113**] Folate->20
[**2125-1-23**] 01:43AM BLOOD TSH-2.0
[**2125-1-22**] 10:29PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HBc-NEGATIVE
.
IMAGING:
[**2125-1-22**] Abdominal U/S With Dopplers: FINDINGS: The liver is
normal in echogenicity and contour. No focal liver lesions are
seen. No intra- or extra-hepatic biliary dilation is identified.
The CBD measures 2 mm. Note is made of a small amount of
ascites. The gallbladder is mildly distended. There is
asymmetric gallbladder wall edema with the wall measuring up to
1 cm. Views of the pancreas are unremarkable, though the distal
tail is obscured by overlying bowel gas. Normal hepatic arterial
and venous waveforms are seen. Normal portal venous flow is
seen.
IMPRESSION:
1. No focal liver lesions. Small amount of intra-abdominal
ascites and
gallbladder wall edema likely related to acute liver
failure/hepatitis.
2. Patent hepatic vasculature with normal waveforms.
.
[**2125-1-23**] Chest X-ray (PA and Lat): No evidence of acute
cardiopulmonary disease. No pneumonia, vascular congestion, or
pleural effusion.
.
[**2125-1-23**] Trans-thoracic Echocardiogram: The left atrium is
elongated. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal study. No structural heart disease or
pathologic flow identified. Normal estimated pulmonary artery
systolic pressure.
Brief Hospital Course:
Mrs. [**Known firstname **] [**Known lastname 89742**] is a 26 year-old woman with history of prior
suicide attempts with overdose of multiple medications
(including acetaminophen), depresion, anorexia, anxiety and
hypothyroidism who comes after a suicidal attempt with 150
tablets of extre-strength tylenol on [**1-19**] at about 2pm on
[**2125-1-19**].
.
#. Tylenol induced Hepatitis: The patient was treated per
tylenol overdose protocol with NAC. AST and ALT peaked at 7575
and 3777 and have since improved significantly. The most
worrisome makers for high-risk are INR >6.5 and pH <7.3, which
she did not have. Normal protocol recommends 16 hours of NAC and
she got it for longer until her INR was <1.5 x2 days. Currently
her LFTs are improving up to ALT of 1572, AST 74 with INR of
1.1. She is out of the danger window and we would only expect
improvement in those values within the next weeks. She most
likely will recover 100% of her liver function. The albumin is
low, most likely as a negative stress reactant, but may be low
secondarily to the hepatitis or anorexia.
.
#. Depression / Suicidal attempt: Pt severly depressed and given
current and past episodes of SI/SA she is at high risk for
recurrence. She was placed on a 1:1 sitter, evaluated by
pscyhiatry, and discharged to inpatient psychiatry [**Hospital1 **].
.
#. Leukopenia: The patient developed leukopenia with a nadir of
2.2 WBC, which was thought to be secondarely to
stress/famotidine. This is also corroborated by the anemia with
low-reticulocyte count (see below). There was also a temporal
relationship with starting famotidine, which was stopped her
absolute neutrophil count is 1500. We expect the WBC to continue
improving back to her baseline. We should encourage good PO
intake. There is no need to trend this lab.
.
#. Anemia: Normocytic, normochromic anemia with normal RDW. She
has an iron/TIBC <15 (8%) with a ferritin of ~600 (most likley
falsely elevated given stress). Her MCV is in the high level of
normal (90s). Reticulocyte count was inappropriately low likely
due to bone marrow suppression from severe illness. B12 and
folate levels were normal.
.
#. Elevated INR: The patient's INR is downtrending and nearly
normal at 1.1. It is now to expected to remain normal.
.
#. Anorexia - Pt's BMI is 17.2 with a weight of 49.9 kg (80% of
her IBW of 60.2 Kg). She is tolerating diet well and her
electrolytes are within normal limits. Her WBC are low as
described above. She should be evaluated by nutrition and
psychiatry during her inpatient psychiatry stay. She should
have bone mineral density testing as an outpatient and receive
daily vitamin and mineral (neutra-phos) supplementation.
.
#. Hypothyroid - The patient is hypothyroid. She was continued
on her home dose of levothyroxine 88 mcg daily. A TSH was
checked and found to be wnl at 2.0.
.
#. Code - Full code
.
#. Contact: mother: [**Telephone/Fax (1) 89757**]
.
#. Transition of Care: The patient should be set-up with an
outpatient psychiatric provider and also have primary care
follow-up after her inpatient psychiatric course.
Medications on Admission:
Levothyroxine 88mcg daily
N-acetylcystine 310mg/hr
Famotidine 20mg PO BID
Discharge Medications:
1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. potassium & sodium phosphates 280-160-250 mg Powder in Packet
Sig: One (1) Powder in Packet PO DAILY (Daily).
4. Outpatient Lab Work
Please check CBC with Diff, AST, ALT, and INR on [**2125-1-29**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Tylenol Induced Hepatitis, Depression
Secondary Diagnoses: Anorexia, Leukopenia, Anemia,
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for tylenol overdose. You
were treated with a medication to decrease the toxicity from
tylenol. You were monitored in the ICU and then transferred to
the medical liver service. You were seen by psychiatry who
recommended inpatient psychiatric treatment for depression. You
are discharged to an inpatient psychiatric hospital.
.
The following changes were made to your medications:
You should START taking Vitamin D.
You should START taking Neutra-Phos.
.
It was a pleasure taking care of you.
Followup Instructions:
Please follow-up with your PCP 2-4 weeks after you are
discharged.
|
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51,347
| 140,544
|
42370
|
Discharge summary
|
report
|
Admission Date: [**2196-11-23**] Discharge Date: [**2196-11-30**]
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] year old female with a PMH notable for CAD s/p 4V
CABG in [**2180**] in [**State 760**], atrial fibrillation on coumadin,
long standing diastolic CHF with most care received at [**Hospital1 112**],
anxiety, who presented to an outside hospital today with
palpitations and dyspnea in the setting of dietary indiscretions
and admitted to the CCU with presumed acute on chronic CHF
exacerbation.
.
She initially presented to the [**Hospital1 882**] ED, where she was found
to have troponin I of 0.4, CK of 128 CKMB not performed creatine
of 2.0, BNP of 16,000. ECG notable for ?ST dep in II, III,
V4-V6. She was given aspirin 325mg PO X 1, was placed on a
nitro gtt and bipap. She was also given lasix 80 mg IV X 1 in
addition to the 80 mg po lasix that she had taken earlier in the
day.
.
She was transferred to [**Hospital1 18**] for further evaluation, where
initial vital signs were: P: 79, BP: 112/60, O2sat: 93% on
Bipap. Her Bipap was weaned off and she was noted to have an
O2sat of 98% on 50% ventimask. Her nitro gtt has also been
weaned. Her labs were notable for a WBC of 12.6, troponin T of
0.81, lactate of 3.3, potassium of 5.7, and creatinine of 2.4
(unclear baseline). U/a was unremarkable. ECG demonstrated ST
dep in II, III V4-V6 pt in afib. Chest radiograph significant
for mild pulmonary edema and cardiomegaly. She was started on
heparin gtt and admitted to the CCU for presumed acute on
chronic CHF exacerbation/NSTEMI.
.
On the floor, patient reports that her breathing has improved.
She denies any chest discomfort. States she is usually very
compliant with her medications and diet at home, had perhaps
deviated a little with her diet on [**Holiday **] Eve more than a
week ago. Her husband did mention that her weight was up by 2
lbs several days, however, the daily recorded weights did not
reflect this change.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
- CAD s/p 4v CABG
- Atrial fibrillation on Coumadin
- dCHF (EF 60% in [**2196-1-19**])
- CRF (baseline Cr 1.4)
- Anxiety
Social History:
lives with husband on [**Location (un) **], daughter lives on [**Location (un) 470**].
- Tobacco history: never a smoker
- ETOH: denies, has not used in years
- Illicit drugs: denies
Family History:
non contributory
Physical Exam:
ON ADMISSION:
VS: T 95.8 BP 125/67 RR 26 HR 85 O2 sat 96% on 50% ventimask
GENERAL: elderly pleasant thin female, Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of to the angle of the jaw
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular rhythm, 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. diffuse crackles 1/2 up
the lungs bilat
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.
.
AT DISCHARGE:
VSS.
GENERAL: elderly pleasant thin female, Oriented x3. Mood, affect
appropriate.
HEENT: EOMI.
NECK: Supple, JVP 10-12 cm
CARDIAC: irregularly irregular rhythm, normal S1, S2. No m/r/g.
LUNGS: crackles 1/3 up the lungs bilat
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e.
Pertinent Results:
CBC:
[**2196-11-23**] 01:40AM BLOOD WBC-12.6* RBC-4.20 Hgb-11.9* Hct-36.6
MCV-87 MCH-28.3 MCHC-32.5 RDW-14.2 Plt Ct-268
[**2196-11-27**] 04:43AM BLOOD WBC-9.9 RBC-3.76* Hgb-10.7* Hct-32.4*
MCV-86 MCH-28.4 MCHC-32.9 RDW-13.7 Plt Ct-285
ADM DIFF:
[**2196-11-23**] 01:40AM BLOOD Neuts-91.3* Lymphs-5.7* Monos-2.7 Eos-0.1
Baso-0.2
ELECTROLYTES:
[**2196-11-23**] 01:40AM BLOOD Glucose-200* UreaN-53* Creat-2.4* Na-139
K-5.7* Cl-104 HCO3-21* AnGap-20
[**2196-11-23**] 05:23PM BLOOD Glucose-171* UreaN-61* Creat-2.2* Na-136
K-6.7* Cl-102 HCO3-22 AnGap-19
[**2196-11-25**] 05:30AM BLOOD Glucose-153* UreaN-94* Creat-2.4* Na-143
K-4.2 Cl-100 HCO3-31 AnGap-16
[**2196-11-25**] 03:55PM BLOOD Glucose-274* UreaN-103* Creat-2.6* Na-140
K-4.1 Cl-96 HCO3-30 AnGap-18
[**2196-11-27**] 04:43AM BLOOD Glucose-162* UreaN-119* Creat-2.6* Na-139
K-4.3 Cl-95* HCO3-29 AnGap-19
[**2196-11-27**] 04:43AM BLOOD Calcium-8.5 Phos-6.0* Mg-2.9*
COAGS:
[**2196-11-23**] 09:20AM BLOOD PT-33.5* PTT-73.8* INR(PT)-3.3*
[**2196-11-26**] 06:43AM BLOOD PT-17.3* PTT-28.6 INR(PT)-1.6*
[**2196-11-27**] 04:43AM BLOOD PT-15.4* INR(PT)-1.4*
[**2196-11-28**] INR 1.3
CARDIAC ENZYMES:
[**2196-11-23**] 01:40AM BLOOD CK(CPK)-193
[**2196-11-23**] 09:20AM BLOOD CK(CPK)-285*
[**2196-11-24**] 05:20AM BLOOD CK(CPK)-185
[**2196-11-23**] 01:40AM BLOOD CK-MB-19* MB Indx-9.8*
[**2196-11-23**] 01:40AM BLOOD cTropnT-0.81*
[**2196-11-23**] 09:20AM BLOOD CK-MB-26* MB Indx-9.1* cTropnT-1.19*
[**2196-11-24**] 05:20AM BLOOD CK-MB-10 MB Indx-5.4 cTropnT-1.25*
[**2196-11-25**] 05:30AM BLOOD cTropnT-1.39*
LACTATE:
[**2196-11-23**] 01:56AM BLOOD Lactate-3.3*
[**2196-11-23**] 05:40PM BLOOD Lactate-2.7*
[**2196-11-24**] 05:15AM BLOOD Lactate-3.0*
URINE:
UA:
[**2196-11-23**] 01:40AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2196-11-23**] 01:40AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2196-11-23**] 01:40AM URINE RBC-<1 WBC-0 Bacteri-MANY Yeast-NONE
Epi-0
[**2196-11-28**] 09:48AM URINE RBC-39* WBC->182* Bacteri-MANY Yeast-NONE
Epi-<1
[**2196-11-28**] 09:48AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
URINE LYTES:
[**2196-11-23**] 08:06AM URINE Hours-RANDOM UreaN-301 Creat-60 Na-46
K-78 Cl-92
[**2196-11-23**] 08:06AM URINE Osmolal-349
[**2196-11-28**] 06:50AM BLOOD Glucose-139* UreaN-135* Creat-2.9* Na-139
K-4.2 Cl-92* HCO3-31 AnGap-20
[**2196-11-28**] 09:48AM URINE Eos-NEGATIVE
[**2196-11-23**] 08:06AM URINE Hours-RANDOM UreaN-301 Creat-60 Na-46
K-78 Cl-92
[**2196-11-28**] 09:48AM URINE Hours-RANDOM UreaN-491 Creat-61 Na-50
K-59 Cl-57
MICRO:
URINE CULTURE (Final [**2196-11-24**]): NO GROWTH.
IMAGING:
ECG [**2196-11-23**]: Atrial fibrillation with a controlled ventricular
response. Probable left ventricular hypertrophy with
repolarization changes. Intraventricular conduction delay. Poor
R wave progression across the precordium. There are T wave
inversions in leads I and aVL with ST segment depressions in
leads V4-V5 raising the possibility of active myocardial
ischemia. Clinical correlation is suggested. No previous tracing
available for comparison.
CXR [**2196-11-23**]
FINDINGS: Heart size is enlarged. There is mild interstitial
pulmonary
edema. Left pleural effusion may be present. No pneumothorax is
seen.
Sternal wires appear intact.
IMPRESSION: Mild pulmonary edema and cardiomegaly.
CXR [**2196-11-25**]
IMPRESSION: AP chest compared to [**11-23**]:
Patient has had median sternotomy and coronary bypass grafting.
Cardiomegaly is severe with a large right heart component.
Perihilar opacification predominantly in the upper lungs
persists, but has improved in the lower lungs. I think this is
probably pulmonary edema, since there is accompanying small left
pleural effusion. It will be very helpful to have conventional
views including a lateral.
Thoracic aorta is heavily calcified, but at least in the upper
descending
portion, not dilated.
Brief Hospital Course:
This is a [**Age over 90 **] year old female with a PMH notable for CAD s/p 4V
CABG, atrial fibrillation on coumadin, long standing diastolic
CHF now here with dyspnea likely [**12-22**] acute on chronic CHF
exacerbation.
.
# Acute on chronic systolic CHF: Pt presenting with dyspnea.
Broad differential, but in the setting of known CHF, evidence of
volume overload on exam, elevated BNP, and chest radiographic
findings of pulmonary edema, most likely acute on chronic left
sided systolic congestive heart failure as the most likely
etiology, likely [**12-22**] dietary indiscretion vs afib with RVR. Pt
initially placed on facemask, with diuresis oxygenation improved
and pt maintained on 2L NC throughout majority of hospital stay.
Pt was initially given lasix but remained at roughly net even,
started on a lasix drip with some improvement in diuresis. Also
given metolazone without much effect. Finally put on daily
torsemide with successful diuresis.
#[**Last Name (un) **] on [**Name (NI) 2091**] - pt developed [**Last Name (un) **] likely from overdiuresis with
creatinine peaking at 2.8 from baseline of 1.6. FeUrea was 20%
on admission consistent with prerenal azotemia due to poor renal
perfusion, in this case likely secondary to CHF. Urine
eosinophils were negative. With aggressive diuresis Cr continued
to trend up. This was felt to be secondary to overdiuresis which
was done to relieve her shortness of breath in the setting of
heart failure, see above. Renal was consulted and they felt that
with PO hydration this would improve. They suggested that should
things persist a renal ultrasound could also be considered and
recommended pt establish a nephrologist and follow up with them
as an outpatient. Pt was started on sevelamer for
hyperphosphatemia per renal recs.
#elevated cardiac enzymes: trops elevated at 0.8 on admission
and went up to 1.39. CKMB peaked at 26 on [**2196-11-23**]. Patient with
known history of 4V CABG. Initial concerning ECG changes
quickly resolved. Troponin T elevation was felt to be [**12-22**] CHF
exacerbation, ARF. ACS unlikely. Pt was continued on ASA 81mg
daily. Her home [**Last Name (un) **] was held given [**Last Name (un) **] (see [**Last Name (un) **]). Metoprolol and
statin (home doses) restarted and continued. Heparin drip had
been started at OSH and it was DCd. Home warfarin restarted for
Afib.
.
#Decreased urine output: Pt developed decreased urine output in
the setting of aggressive diuresis in attempts to relieve SOB
from CHF exacerbation. This resolved after cessation of diuretic
therapy.
.
# Atrial Fibrillation: Currently rate controlled, on coumadin as
an outpatient. INR subtherapeutic as coumadin had been DCd in
setting of initial heparin administration. Home doses were
resumed and INR trended up to therapeutic range. Pt was
monitored on telemetry and maintained on beta blocker.
.
# Leukocytosis: Pt with WBC of 10.8 on admission which quickly
resolved without intervention. Pt was afebrile. On [**2196-11-28**] she
was found to have a UTI and ceftriaxone was started. Prelim
culture showed gram negative rods.
.
#anxiety - initially in first 2-3 days of hospitalization pt
demonstrated extreme anxiety with HR up to 130s. HR and anxiety
improved with only 0.125mg ativan.
.
# HTN: well-controlled. Allowed permissive HTN to help improve
renal perfusion. Diovan was held in setting of renal failure.
Amlodipine and metoprolol initially held as well, but metoprolol
restarted.
.
#DISPO - PT saw pt and felt it was fine for her to go home with
her daughter. Pt lives with her husband who can also help with
ADLs. Pt appears to get all of her other care at [**Hospital1 112**].
Appointments were set up for her to follow up with her regular
physicians there. Cardiologist is [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 17976**] [**Telephone/Fax (1) 33529**].
PCP is [**Name9 (PRE) **] [**Name9 (PRE) **] at Center for Older Adult Health.
.
Transitional Care Issues:
1. Consider repeat echocardiogram as an outpt at [**Hospital1 112**] per the
discretion of cardiology to evaluate EF for interval change.
Medications on Admission:
-Amlodipine 5 mg po Daily
-Metoprolol tartrate 12.5 mg Daily
-Diovan 240 mg po Daily
-Simvastatin 10 mg po Daily
-Lasix 80 mg po Daily
-lorazepam 0.25 mg po BID as needed anxiety
-Klor-Con 20 mEq po Daily, 30 meq two days/week
-Dorzolamide 2 % Eye Drops Ophthalmic Three times daily
-Travatan Z 0.004 % Eye Drops Ophthalmic Once Daily
-Coumadin 2 mg sun, tues, thurs; Coumadin 1 mg mon, wed, fri,
sat
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. dorzolamide 2 % Drops Sig: One (1) Ophthalmic tid ().
5. lorazepam 0.5 mg Tablet Sig: [**11-21**] Tablet PO twice a day as
needed for sleep/anxiety.
6. travoprost 0.004 % Drops Sig: One (1) Ophthalmic daily ().
7. Outpatient Lab Work
Pls check INR, Chem-7 on Friday [**12-2**] with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] at Phone: [**Telephone/Fax (1) 9750**]
Fax: [**Telephone/Fax (1) 91762**]
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
9. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 4 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY
congestive heart failure exacerbation
SECONDARY
Coronary artery disease s/p 4 vessel CABG [**2180**]
Afib on coumadin
diastolic CHF (EF 60% in [**2196-1-19**])
chronic kidney disease (baseline Cr 1.4)
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable, sometimes alert
and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You were admitted with shortness of breath from
a congestive heart failure exacerbation. We gave you diuretics
to remove excess fluid from the body. We put you on oxygen to
keep your blood oxygen levels up. There was concern initially
that you had a heart attack but on more thorough review and more
lab testing we felt this was not the case.
We made the following CHANGES to your medications:
STOPPED diovan
STOPPED lasix
STOPPED amlodipine
STOPED klor-con (potassium)
STARTED aspirin
STARTED torsemide
STARTED sevelamer
STARTED cefpodoxime (4 more days)
We changed your coumadin dosing (was 2 mg sun, tues, thurs;
Coumadin 1 mg mon, wed, fri, sat at home) home on 2mg every
day. You should have your INR checked on Friday [**12-2**].
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days.
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Specialty: NEPHROLOGY
Location: [**Hospital6 9657**] HOSPITAL
Address: [**Doctor First Name **], 2ND FL, [**Location (un) **],[**Numeric Identifier 9749**]
Phone:[**Telephone/Fax (1) 78950**]
Appointment: WEDNESDAY [**12-7**] AT 9AM
Name: [**Month (only) **],JUERGEN H.
Specialty: GERIATRIC MEDICINE
Location: [**Hospital6 9657**] HOSPITAL
Address: [**Doctor First Name **], 2ND FL, [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 9750**]
Appointment: WEDNESDSAY [**12-7**] AT 10:30AM
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital 756**] Medical Specialties at [**Hospital1 882**]
Address: [**Street Address(2) 6802**], [**Location (un) 538**], MA
Phone: [**Telephone/Fax (1) 33529**]
**The office is working on an appt for you in the next few weeks
and will call you at home with the appt. If you dont hear from
them within the next 2 business days, please call the office to
book.
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
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[
[
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238, 245
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13874, 14094
|
12384, 12786
|
14326, 14765
|
3101, 3101
|
3947, 4219
|
14794, 15292
|
10062, 12192
|
179, 200
|
12218, 12358
|
273, 2682
|
3115, 3933
|
14130, 14302
|
2726, 2849
|
2865, 3052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 107,252
|
50317
|
Discharge summary
|
report
|
Admission Date: [**2149-11-10**] Discharge Date: [**2149-11-17**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
CENTRAL VENOUS LINE PLACEMENT
History of Present Illness:
For a full admission note, please see MICU Green note. In brief,
this is a 53 year old woman with PMH significant for T1-T2
paraplegia s/p MVC, recurrent UTI/PNA, chronically on 2L of
oxygen at home, and anxiety who presented to hospital with
shortness of breath and fevers.
.
Caretaker noted her to be breathing faster than normal prior to
admission. She also reports recent dysphagia, concerning for
aspiration pneumonia. At home does intermittently straight-cath,
however she is unable to discern signs/sx of UTI. Per care
taker, she was seen by Dr [**Last Name (STitle) 665**] several weeks again found to
have +UA however no definite culture data so not treated.
.
In the ED she was found to have temp of 100.7 with O2 sat at 84%
on 2L (baseline in low 90s) and SBP in 90s. Her WBC count was
elevated and UA found to be positive. She got 2 L of fluid and
was transferred to the MICU. Of note, she had a PICC line on
admission.
.
While in the MICU, she started treatment for UTI with vanc and
[**Last Name (un) 2830**] given hx of [**Last Name (un) 40097**]. She had a CXR that could not exclude
pneumonia. She was also on levaquin for 3 days for legionella
coverage but this was stopped on [**11-11**] when found to be
negative. She has been getting chest PT and nebs and also
reports some cough. Sputum culture growing coagulase positive
staph and gram negative rods.
She had 1 positive blood cx for coag negative staph and PICC
line was pulled.
.
Prior to transfer to the floor her blood pressure was in low
100s, she was mentating well and had no active complaints.
Past Medical History:
#T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]
Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies.
Family History:
Mother passed away with lung disease.
Physical Exam:
Physical Exam on Arrival to the MICU
VS: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 65 (62 - 80) bpm
BP: 83/47(55) {83/45(55) - 93/74(77)} mmHg
RR: 17 (12 - 23) insp/min
SpO2: 99%
General: Alert, oriented, agitated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge exam
VS 96.9 117/72 79 20 97% 2L
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess, no LAD
Lungs: few bibasilar crackles. good aeration
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, bowel sounds present, no rebound
tenderness or guarding
GU: + foley, no suprapubic tenderness
Ext: warm, well perfused, 1+ LE edema halfway up shins. 2+ DP
pulses
Pertinent Results:
[**2149-11-10**] 10:50AM BLOOD WBC-11.7*# RBC-3.51* Hgb-9.6* Hct-30.5*
MCV-87 MCH-27.2 MCHC-31.4 RDW-14.8 Plt Ct-192
[**2149-11-10**] 10:50AM BLOOD Neuts-92.8* Lymphs-5.0* Monos-1.3*
Eos-0.6 Baso-0.3
[**2149-11-10**] 10:50AM BLOOD Glucose-141* UreaN-9 Creat-0.4 Na-140
K-4.2 Cl-100 HCO3-32 AnGap-12
[**2149-11-11**] 03:35AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
[**2149-11-10**] 11:02AM BLOOD Lactate-2.3*
[**2149-11-11**] 03:52AM BLOOD Type-[**Last Name (un) **] pO2-74* pCO2-75* pH-7.26*
calTCO2-35* Base XS-3 Comment-GREEN TOP
[**2149-11-11**] 03:52AM BLOOD Lactate-1.3
[**2149-11-11**] 07:51AM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-87* pH-7.24*
calTCO2-39* Base XS-6
[**2149-11-11**] 12:18PM BLOOD Type-[**Last Name (un) **] pO2-96 pCO2-73* pH-7.28*
calTCO2-36* Base XS-4 Comment-GREEN TOP
[**2149-11-11**] 07:51AM BLOOD Lactate-0.8
.
micro:
**FINAL REPORT [**2149-11-12**]**
URINE CULTURE (Final [**2149-11-12**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
**FINAL REPORT [**2149-11-13**]**
GRAM STAIN (Final [**2149-11-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2149-11-13**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
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
_________________________________________________________
STAPH AUREUS COAG +
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S 2 S
VANCOMYCIN------------ 1 S
CXR [**2149-11-10**]
CHEST, AP AND LATERAL: Patient was unable to raise her arms for
the lateral view, on which bilateral humeral fixation plates and
screws obscure evaluation. Left internal jugular catheter has
been removed. Right PICC again terminates in the mid SVC. There
is no pneumothorax. The lungs are overinflated. Moderate
cardiomegaly persists, with vascular congestion and small
bilateral pleural effusions. Lower lobe opacities
persist, left greater than right. There are old healed
bilateral rib fractures, with associated chest wall deformity.
IMPRESSION:
1. Chronic obstructive airways disease.
2. Congestive heart failure.
3. Bilateral lower lobe opacities may be secondary to #2, but
superimposed
pneumonia is not excluded.
ECHO
The left atrium is elongated. The right atrium is moderately
dilated. 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. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. 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 a very small
pericardial effusion.
IMPRESSION: Suboptimal study. Normal global biventricular
systolic function. Mild pulmonary hypertension. Very small
pericardial effusion.
.
video swallow study
Penetration and aspiration with thin liquids. Chin tuck helps to
limit aspiration with thin liquids. Penetration with
nectar-thick liquids. For details, please refer to speech and
swallow division note in OMR.
.
discharge labs
[**2149-11-17**] 05:50AM BLOOD WBC-4.9 RBC-3.12* Hgb-8.3* Hct-27.2*
MCV-87 MCH-26.5* MCHC-30.4* RDW-14.6 Plt Ct-216
[**2149-11-17**] 05:50AM BLOOD Glucose-81 UreaN-5* Creat-0.2* Na-145
K-4.0 Cl-102 HCO3-40* AnGap-7*
[**2149-11-17**] 05:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
Brief Hospital Course:
53F T1-T2 paraplegia s/p MVC, recurrent UTI/PNA, and anxiety who
is presented with SOB and fever initially admitted to the MICU
found to have UTI and pneumonia which improved with antibiotic
treatment.
.
# UTI - Urine cx showed multi-drug resistant klebsiella (only
sensitive to meropenem and cefepime). Patient started on
meropenem. PICC line placement was unsuccessful and tunneled
line was placed. Patient discharged with plans to complete total
10 day course of antibiotics.
.
# pneumonia - Patient presented with SOB, fever, and increased
O2 requirement. CXR showed R pleural effusion and could not
exclude pneumonia. Also given dysphagia concern for aspiration.
Pleural effusion thought to be parapneumonic vs [**3-5**] to heart
failure (CXR also showed enlarged heart). Echo was done and
showed normal EF.
Component of SOB/hypoxia also thought to be secondary to
hypoventilation from underlying paraplegia. Sputum cultures grew
MRSA and klebsiella. Patient was treated with vancomycin,
meropenum, levofloxacin, nebulizers and chest PT while in the
MICU. Levofloxacin was discontinued prior to transfer to the
floor after urine legionella was found to be negative. Given
difficult access, a tunneled line was eventually placed after
failed PICC attempts. Patient clinically improved and oxygen
requirement returned to baseline 2L. Patient was discharged with
plans to complete total 10 day course of IV antibiotics.
.
# Hypotension. Patient initially presented with SBP in the 90s.
She was given 3L in the ED. BP remained stable in the MICU and
on the floor after fluid resuscitation.
.
# Dysphagia. - followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**] as outpatient. Symptoms
are thought to be related to dysphagia for solid foods, although
there is some question whether there may be over spill into the
larynx as well. Previous endoscopy demonstrated some mild
changes in the esophagus, but no obvious stricture; it is
possible in the interim she has developed a stricture as pt with
h/o tracheostomy. Also note of possible esophageal mass on [**9-11**]
CT, although very small in size. S&S recommended regular diet
with thin liquid and video swallow study. Video swallow study
was completed which showed penetration and aspiration with thin
liquids. Chin tuck helped to limit aspiration with thin liquids.
Also showed penetration with nectar-thick liquids.
Recommendations included thin liquids and moist solids, pills
with puree, and aspiration precautions. Patient has plans to
follow up with outpatient gastroenterologist for further
evaluation and treatment.
.
# Depression/Anxiety - continued clonazepam, citalopram,
trazodone
.
# Hypothyroid - continued levothyroxine
.
# chronic pain - continued baclofen, lyrica, methadone,
lidocaine patches. Also was given oxycodone prn.
.
transitional issues
- complete antibiotics as prescribed
- tunneled line will need to be removed after completion of
treatment
- HCO3 will need to be rechecked as was slightly elevated upon
discharge
- patient was full code on this admission
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - one vial inh 4-6 hours prn
BACLOFEN - 10 mg Tablet - 2 (Two) Tablet(s) by mouth in the
morning; 1 (One) tablet at 4 pm and 2 (Two) tablets at bedtime
CITALOPRAM - 20 mg Tablet - 2 Tablet(s) by mouth once a day
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 2 Tablet(s) by mouth (1
mg) three times a day
ESTRADIOL [ESTRACE] - 0.01 % Cream - apply to exterrnal gyn area
twice a week
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs three times a day
LEVOTHYROXINE - 112 mcg Tablet - 1 (One) Tablet(s) by mouth once
a day
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
four patches to the affected areas once a day 12 hours off and
12
hours on - No Substitution
LIDOCAINE HCL - 5 % Ointment - Apply externally to affected area
once a day as needed for burning
METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth three times daily
for pain
METHENAMINE HIPPURATE - 1 gram Tablet - 1 Tablet(s) by mouth
twice a day take with Vitamin C 500
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
as needed for pain
PREGABALIN [LYRICA] - 100 mg Capsule - 1 Capsule(s) by mouth
three times a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily
SUCRALFATE - (post d/c med) (On Hold from [**2148-8-27**] to
[**2148-9-3**] for while taking levaquin) - 1 gram Tablet - 1
Tablet(s) by mouth four times a day
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime
.
Medications - OTC
CALCIUM CARBONATE [CALCIUM 500] - (Prescribed by Other
Provider)
(On Hold from [**2148-8-27**] to [**2148-9-3**] for while taking
levaquin)
- 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth twice daily pt
unsure if 500mg or 600mg
CATHETER [FOLEY CATHETER] - 14 Fr [**Year (4 digits) 12106**] - Use for urinary
control/self catheterizaion as needed Dx: Neurogenic bladder,
paraplegia (1 month supply)
FACIAL-BODY WIPES [BABY WIPES] - [**Name2 (NI) 12106**] - USE AS DIRECTED PRN
NEBULIZER - Kit - for use in home qd. dx: pneumonia
NICOTINE - (Prescribed by Other Provider) (Not Taking as
Prescribed) - 21 mg/24 hour Patch 24 hr - apply 1 patch daily as
directed
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Not Taking as Prescribed:
not on medication list provided by patient [**2146-6-15**]) - 17 gram
(100 %) Powder in Packet - one pack by mouth once a day
SURGICAL LUBRICANT JELLY [SURGILUBE] - Gel - as needed for
straight cath
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) vial Inhalation Q6H (every 6 hours) as
needed for SOB.
2. baclofen 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a
day).
3. citalopram 20 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily).
4. clonazepam 0.5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO three times a
day.
5. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 5 days: continue until
[**2149-11-21**]. .
Disp:*10 gram* Refills:*0*
6. meropenem 1 gram Recon Soln [**Month/Day/Year **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 5 days: continue through
[**2149-11-21**].
Disp:*QS Recon Soln(s)* Refills:*0*
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
four patches to the affected areas once a day 12 hours off and
12 hours on - No Substitution
.
8. levothyroxine 112 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
9. Combivent 18-103 mcg/Actuation Aerosol Inhalation
10. methadone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3 times a
day).
11. oxycodone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO three times a
day as needed for pain.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. pregabalin 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID (3
times a day).
14. simvastatin 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
15. trazodone 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO at bedtime.
16. Outpatient Lab Work
Please check CBC, Chem 7, Vancomycin trough level on [**2149-11-18**]
and fax results to Dr.[**Last Name (STitle) 665**] FAX#:[**Telephone/Fax (1) 78619**].
17. Outpatient Lab Work
Please check CBC, Chem 7, on [**2149-11-22**] and fax results to
Dr.[**Last Name (STitle) 665**] FAX#:[**Telephone/Fax (1) 78619**].
18. estradiol 0.01 % (0.1 mg/g) Cream [**Telephone/Fax (1) **]: as directed mg
Vaginal twice weekly: apply to external gyn area twice a week
.
19. lidocaine 5 % Cream [**Telephone/Fax (1) **]: as directed cream Topical once a
day as needed for pain: Apply externally to affected area
once a day as needed for burning
.
20. methenamine hippurate 1 gram Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
twice a day: take with Vitamin C 500
.
21. oxybutynin chloride 5 mg Tablet [**Telephone/Fax (1) **]: as directed Tablet PO
as directed: 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1)Pneumonia
2)Urinary Tract Infection
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to our hospital with a concern for a urinary
tract infection and pneumonia. We had trouble obtaining
intravenous access to administer antibiotics, and finally
established it. You will need to have the catheter in for
administration of intravenous antibiotics for a total of 5 more
days. After that you will need to have the catheter removed.
Please keep the catheter site dry and intact.
The following changes were made to your medication regimen:
START Vancomycin
START Meropenem
Followup Instructions:
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2149-11-19**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: WEDNESDAY [**2149-11-19**] at 1 PM
Department: [**Hospital3 249**]
When: WEDNESDAY [**2149-11-26**] at 9:00 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2149-11-17**]
|
[
"V12.51",
"599.0",
"530.9",
"535.10",
"285.29",
"786.09",
"338.29",
"E929.0",
"277.9",
"300.4",
"V44.0",
"276.3",
"787.22",
"496",
"482.42",
"V12.53",
"907.2",
"070.54",
"344.1",
"041.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18282, 18337
|
9781, 12849
|
279, 311
|
18419, 18534
|
4066, 9758
|
19154, 19972
|
2851, 2891
|
15541, 18259
|
18358, 18398
|
12875, 15518
|
18595, 19131
|
2906, 4047
|
231, 241
|
339, 1915
|
18549, 18571
|
1937, 2654
|
2670, 2835
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,458
| 150,759
|
23739
|
Discharge summary
|
report
|
Admission Date: [**2134-3-13**] Discharge Date:
Date of Birth: [**2134-3-13**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 60634**] is a 2.91 product of a term
gestation with a prenatal diagnosis of trisomy 21. She was
admitted to the NICU for management of hyperbilirubinemia.
She was born to a 42 year old G3 P1 now 2 mother. Prenatal
screens O positive, antibody negative, hepatitis surface
antigen negative, RPR nonreactive, rubella immune, GBS
unknown. Pregnancy complicated by maternal history of AMA,
Raynaud's, thoracic outlet syndrome, amniocentesis consistent
with trisomy 21, normal fetal scans and echocardiogram.
Mother presented in spontaneous labor. No maternal fever.
Spontaneous rupture of membranes less than 24 hours prior to
delivery for clear amniotic fluid. The infant was delivered
vaginally and received Apgars of 8 and 9.
PHYSICAL EXAM ON ADMISSION: Comfortable in Isolette under
phototherapy. Anterior fontanel soft and flat. Low set ears.
Eyes deferred at this time. Neck supple. Lungs clear to apex
and equal. Cardiovascular - Regular rate and rhythm, no
murmur. Good peripheral pulses. Abdomen soft, positive bowel
sounds. Genitourinary - Normal female. Hips stable, pink and
well perfused and jaundiced.
HISTORY OF HOSPITAL COURSE BY SYSTEM: RESPIRATORY: [**Known lastname **] has
been stable on room air throughout her neonatal intensive
care unit stay.
CARDIOVASCULAR: Initially received normal saline bolus for
polycythemia. Otherwise has been cardiovascularly stable. In
light of the prenatal diagnosis of trisomy 21, Cardiology was
consulted. An echocardiogram was performed. Noted to have
small membranous VSD with some right ventricular hypertension
and a patent foramen ovale. Recommended follow up with Dr.
[**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 30103**] in 1 month.
FLUID AND ELECTROLYTES: Admitted to the newborn intensive
care unit with a 10 percent weight loss. Her birth weight was
2910; admission weight to the NICU was 2645. She was on a
minimum of 120 cc/kg/day of breast milk or Similac 20
calorie, requiring some p.g. feeds. She is currently taking
adequate amounts, with a minimum of 120/kg of breast milk or
Similac 20. Her discharge weight is 2855 grams.
GASTROINTESTINAL: Peak bilirubin was 20.8/0.5 on day of life
2. Infant received phototherapy. Was discontinued on [**3-18**]. Rebound bilirubin was 11.3/0.3 on [**3-19**]. This issue
has since resolved.
HEMATOLOGY: The patient's blood type is B positive, Coombs
negative. Her initial hematocrit was 65.8. Her most recent
hematocrit was 60.1. She has not required any blood
transfusions during this hospital course.
INFECTIOUS DISEASE: No sepsis risk factors.
NEUROLOGY: Has been appropriate for gestational age, with low
tone consistent with trisomy 21.
SENSORY: Audiology - Hearing screen was performed and was
referred bilaterally. A hearing screen follow up was
scheduled at [**Hospital3 1810**] for [**2134-4-15**] at 10:30
a.m.
PSYCHOSOCIAL: A social worker has been involved with the
family and can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 60635**], [**Telephone/Fax (1) 56712**].
CARE RECOMMENDATIONS:
1. Continue ad lib feedings, breast milk or Similac 20
calories.
2. Medications: Not applicable.
3. Car seat position screening: Not applicable.
4. State newborn screens have been sent per protocol, and
have been within normal limits. Most recently sent on
[**3-16**].
5. Immunizations received: Hepatitis B vaccine on [**2134-3-18**].
6. Followup appointments scheduled: Cardiology with Dr. [**First Name8 (NamePattern2) 553**]
[**Last Name (NamePattern1) 30103**] on [**4-7**] at 1:30 p.m. ([**Telephone/Fax (1) 60636**]). Hearing
screen at [**Hospital3 1810**] on [**Last Name (un) 9795**] 11 ([**Telephone/Fax (1) 60637**])
on [**4-15**] at 10:30 a.m. Down syndrome clinic at [**Hospital1 55707**] ([**Telephone/Fax (1) 60638**]). To be followed with visiting
nurses from care group ([**Telephone/Fax (1) 14297**]), and Criterion
[**Location (un) 2199**] Early Intervention Center ([**Telephone/Fax (1) 36248**]).
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2134-3-19**] 23:58:52
T: [**2134-3-20**] 01:10:32
Job#: [**Job Number 60639**]
|
[
"758.0",
"V05.3",
"V30.00",
"402.90",
"774.6",
"745.4",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.55",
"99.83"
] |
icd9pcs
|
[
[
[]
]
] |
3308, 4519
|
1310, 3129
|
911, 1282
|
3154, 3286
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,748
| 151,837
|
18973
|
Discharge summary
|
report
|
Admission Date: [**2122-9-5**] Discharge Date: [**2122-9-6**]
Date of Birth: [**2049-3-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
Placement of Right Femoral Cordis
History of Present Illness:
The patient is a 73 y.o. female with h/o duodenal adenocarcinoma
(dx in [**2-14**] @[**Hospital1 112**]) h/o epidoses of hematemesis, h/o CAD s/p
stent placement, ?h/o esophageal cancer? per nursing home
records but not found in records from [**Hospital6 **], who
presents from a nursing home after an episode of hematemesis.
In the ED she was found to be hypotensive to 74/42, tachy to
120s and HCT = 23. She was given protonix 40 mg IV x T, IVF, R
fem cordis placed, transfused 1 unit then transferred to the
MICU. Of note her ECG in the ED demonstrated ST depressions in
leads V2 and V3. Upon transfer to the MICU the patient was
tachycardic to 110s, SBPs = 90-120. An NGT was placed and NG
lavage produced blood which did not clear even after lavaging
with 1L.
Past Medical History:
PMH:
1. h/o duodenal dysplasia then found to have duodenal adenoCA
diagnosed at [**Hospital1 112**] in [**2-14**]. Not a surgical candidate
2. NSTEMI in [**7-12**] with EF = 60% on echo in [**2121**] with RVH and
depressed RVEF
3. Diabetes.
4. Chronic atrial flutter (times 10 years).
5. Status post cerebrovascular accident in [**2107**] with
residual facial droop.
6. Hypertension.
7. Status post herniorrhaphy.
8. Status post bladder surgery.
Social History:
Shx:
Patient currently lives at [**Location 1188**] house where she was
transferred to a hospice program but remains full code. She used
to live with her daughter, grandaughter, [**Name2 (NI) 802**] who is pregnant
[**Last Name (NamePattern1) 51857**] Project in a 2 bedroom appt. The appartment is
in her grandmother's name and no one else is on the lease. On a
more emotional level her daughter (HCP) would like her mother to
meet her unborn baby. Apparently when she was well, her mother
stated that she wants to live at all cost and her daughter
believes that she is not in her right mind because she is so
tired because of her illness.
Family History:
Brother with heart disease.
Physical Exam:
Vitals: Tm = 99.2, HR = 90s-112, currently 102, BP =
90-120/60-80,
Gen: Thin elderly female, NAD, A&O 3. Can state name of of
president.
CV: tachy, nml S1, S2, no m/r/g
Lungs: CTAB
Abd: soft, nt, guaic negative brown stool.
Extremities: R femoral cordis in place. No other access besides
cordis.
Pertinent Results:
Admission CXRay:
IMPRESSION:
1. Findings consistent with congestive heart failure.
2. Interval opacity in left lower lung zone; underlying effusion
or consolidation cannot be ruled out. Ideally, a PA and lateral
chest radiograph should be obtained for complete evaluation.
*
CT ABDOMEN W/CONTRAST [**2122-9-5**] 8:57 AM
CT ABDOMEN W/CONTRAST; CT CHEST W/CONTRAST
Reason: HEMATEMESIS, ESOPHAGEAL CA, HYPOTENSION, ? BLEED, ? MASS
Field of view: 32 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with hx of esophageal CA p/w hematemesis,
hypotension.
REASON FOR THIS EXAMINATION:
IV contrast eval for bleed.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Esophageal cancer and hematemesis. Evaluate for
hemorrhage and metastatic disease.
COMPARISON: CTA of the chest dated [**2121-9-1**].
TECHNIQUE: Contiguous axial images through the chest, abdomen,
and pelvis were obtained following the administration of 150 cc
of Optiray contrast. As the patient was actively bleeding from
the upper GI tract, the referring service requested no oral
contrast.
CT OF THE CHEST WITH IV CONTRAST: There are no pathologically
enlarged axillary, mediastinal or hilar lymph nodes that are
definitely identified. There is some soft tissue density in the
subcarinal region, but a discrete lymph node is not definitely
identified. There are small bilateral pleural effusions, and the
left pleural effusion tracks medially with a small amount of
low-attenuating fluid surrounding the descending thoracic aorta.
Within the left lung apex, there is a 4 mm nodule which is new
compared to the prior study of [**2121-8-10**]. No additional lung
nodules are identified. There are no consolidations. There is
bilateral minimal dependent atelectasis associated with the
small pleural effusions. There is no pericardial effusion. The
central airways are patent. A small lymph node is noted at the
gastroesophageal junction, measuring 7 mm in short axis
dimension.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, pancreas and
adrenal glands are normal. The gallbladder is somewhat
distended. There is relative low attenuation that is ill defined
in the inferior aspect of the spleen, which is nonspecific. The
kidneys enhance symmetrically and excrete normally. There is a
rounded hypoattenuating lesion on the lower pole of the right
kidney measuring 2.8 x 3.1 cm. It likely represents a cyst, as
it measures 8.7 Hounsfield units. The stomach contains a fair
amount of mixed attenuation material with air. The small bowel
is not dilated. The colon is unremarkable. The aorta is of
normal caliber, and the celiac, SMA, renal arteries and proximal
[**Female First Name (un) 899**] are patent. There is atherosclerosis of the abdominal aorta.
Small retrocrural lymph nodes are noted, which do not meet CT
criteria for pathologic enlargement. They measure approximately
6-7 mm in short axis dimension. Small mesenteric lymph nodes are
noted that do not meet CT criteria for pathological enlargement
as well.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid, and
uterus are normal. There is a Foley catheter within the bladder,
with associated air. No pathologically enlarged pelvic or
inguinal lymph nodes.
BONE WINDOWS: There is a small amount of cystic change with
associated sclerosis of the right ilial portion of the superior
sacroiliac joint, likely degenerative. No other osseous lesions
are noted.
IMPRESSION:
1. No areas of active extravasation. There is a fair amount of
mixed attenuation material within the stomach.
2. A 7-mm lymph node at the gastroesophageal junction and small
retrocrural lymph nodes. While these small lymph nodes do not
meet CT criteria for pathologic enlargement, attention on
follow-up studies is recommended to evaluate for interval growth
and evaluation of possible metastases.
3. New 4 mm nodule within the left lung apex.
4. Small bilateral pleural effusions.
5. Coronary artery calcifications and calcification of the
abdominal aorta.
*
Admission ECG:
Brief Hospital Course:
A/P 73 y. o. female with h/o CAD, s/p stent, h/o duodenal
cancer, h/o admissions with UGI bleed p/w UGI bleed.
UGI bleed:
We thought that her hematemesis was most likely secondary to her
duodenal cancer. We obtained records from [**Hospital1 756**] which clearly
demonstrated that she had not been considered to be a candidate
for surgery and she had refused chemotherapy. She is s/p
radiation therapy which she completed in 04/[**2122**]. A CT scan was
obtained which did not demonstrate an acute GI process. She was
then aggressively transfused and her HCT remained stable. The
case was discussed with GI who thought that an EGD would offer
little therapeutic benefit and in light of the risks associated
with the procedure an EGD was not performed. Her HCT remained
stable and thus her diet was advanced to CLD. She was continued
on a proton pump inhibitor [**Hospital1 **].
*
ECG changes:
The patient remained chest pain free and cardiac ischemia was
ruled out by serial flat cardiac enzymes. She was not given an
aspirin in light of her risk of bleeding and she continued on a
statin.
*
FEN:
She was initially NPO and then her diet was slowly advanced to
clear liquids. Her potassium and magnesium were repleted. Her
sodium was elevated on the day of discharge and she was
encouraged to drink fluids to correct her sodium. Her free water
deficit was calculated to be 1L.
*
Prophylaxis:
She was continued on a proton pump inhibitor [**Hospital1 **], compression
boots, subpx: PPI IV bid, SCDs. SQ heparin was held secondary to
bleeding.
*
Disposition: To return to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] today for hospice care.
*
Code Status:
Upon admission she was felt to be CPR not indicated although her
code status was a full code. Upon discussion with the patient
she clearly expressed her desire to be comfortable and she also
longed to spend just a few hours at home before she dies. She
understands that her family is not able to care for her at home
and thus she is willing to return to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. After
intense discussions the family accepted her wish to be DNR/DNI
and Do Not Hospitalize.
*
Medications on Admission:
Meds in NH:
Tylenol
Lorazepam
Bisacodyl 10 mg supp
Ritalin 5 mg
Morphine 15mg SR [**Hospital1 **]
Mirtazapine 7.5 qhs
Prochlorperazine 10 mg q 8 prn
Prochlorperazine 25 mg supp q 8 prn nausea
Hyoscyamine 0.125 Sl PRN increased secretions
Morphine 20 mg /ml give 0.5ML q 1-2 hrs prn pain
Morphine .75 ML - 15 mg LS prn pain
Discharge Medications:
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Morphine 10 mg/5 mL Solution Sig: [**1-11**] PO Q3H (every 3 hours)
as needed.
3. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Duodenal Cancer with upper GI bleed
Secondary:
1. CHF with EF = 60%
2. Diabetes.
3. Chronic atrial flutter (times 10 years).
4. Status post cerebrovascular accident in [**2107**] with
residual facial droop.
5. Hypertension.
6. Status post herniorrhaphy.
7. Status post bladder surgery.
Discharge Condition:
Fair, back to baseline.
Discharge Instructions:
DNR/DNI transitioning to hospice.
Followup Instructions:
Please follow up with your doctor [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
|
[
"438.83",
"152.0",
"414.01",
"285.1",
"578.9",
"V45.82",
"427.32",
"428.0",
"250.00",
"401.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9559, 9632
|
6697, 8902
|
327, 362
|
9971, 9997
|
2666, 3134
|
10079, 10221
|
2304, 2334
|
9276, 9536
|
3171, 3244
|
9653, 9950
|
8928, 9253
|
10021, 10056
|
2349, 2647
|
273, 289
|
3273, 6674
|
390, 1156
|
1178, 1626
|
1642, 2288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,270
| 195,344
|
1657
|
Discharge summary
|
report
|
Admission Date: [**2181-5-20**] Discharge Date: [**2181-6-19**]
Date of Birth: [**2133-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zosyn / Seroquel
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
[**2181-5-26**] Endotracheal intubation
[**2181-5-27**] PICC placement
[**2181-5-31**] central line placement
[**2181-6-11**] cardiac catheterization
[**2181-6-15**] Coronary artery bypass graft surgery x 5 (left
internal mammary artery > left anterior descending, saphenous
vein graft > diagonal, saphenous vein graft > obtuse marginal,
saphenous vein graft > posterior descending artery > PLV)
History of Present Illness:
47 year old male who complains of CARDIAC ARREST. 47-year-old
man transferred from outside hospital per a friend he is only a
history of hypertension and was
normal all weekend. Today while riding a bike race he had a
witnessed collapse. Bystander CPR was in nearly started and
within 5 minutes a basic life support team arrived and placed in
the AED was recommended a shock. After one shock
it return spontaneous circulation. At the outside hospital he
was hypertensive and withdrawn only to painful stimuli. An EKG
showed Q waves inferiorly and anteriorly. A CT head neck and
abdomen was negative. A chest CT was not performed.
Past Medical History:
Hypertension
Social History:
Mr. [**Known lastname 9579**] is divorced with two children
Per friends he does not smoke, use drugs, or drink alcohol.
Family History:
non contributory
Physical Exam:
VS: T (on Arctic Sun) 91.2 (Bladder), 92.1 (Rectal) BP=157/109
HR=56 RR=16 O2 sat=100% on CMV/Assist
GENERAL: Intubated and sedated.
HEENT: NCAT. Sclera anicteric. ET tube in place. Pupils 2mm and
sluggish bilaterally.
NECK: In cervical collar.
CARDIAC: RR, normal S1, S2. No m/r/g appreciated, though
difficult exam on this patient who is intubated.
LUNGS: Occasional inspiratory wheeze.
ABDOMEN: Soft, nondistended, +BS.
EXTREMITIES: No c/c/e. Cool to the touch.
NEURO: Not assessed in sedated and paralyzed patient other than
pupils as above.
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Left Atrium - Long Axis Dimension: *5.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Aorta - Annulus: 2.7 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.4 cm <= 3.0 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
LEFT ATRIUM: Moderate LA enlargement. Good (>20 cm/s) LAA
ejection velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the
basal septum. Normal LV cavity size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Normal descending aorta
diameter. Simple atheroma in descending aorta. No thoracic
aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+)
AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: Very small pericardial effusion.
PRE-CPB:
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
Thereis mild (non-obstructive) focal hypertrophy of the basal
septum. 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 ascending aorta is mildly dilated. There are simple atheroma
in the descending thoracic aorta. No thoracic aortic dissection
is seen. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Mild
(1+) aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is a very small pericardial effusion.
POST-CPB:
The LV systolic function remains normal, estimated EF>60%. There
is no change in valvular function. There is no evidence of
aortic dissection.
[**2181-6-19**] 05:47AM BLOOD Hct-24.2*
[**2181-6-18**] 05:06AM BLOOD WBC-5.7 RBC-2.69* Hgb-8.4* Hct-23.7*
MCV-88 MCH-31.3 MCHC-35.7* RDW-15.5 Plt Ct-196
[**2181-5-20**] 06:20PM BLOOD WBC-12.1* RBC-4.89 Hgb-16.0 Hct-42.9
MCV-88 MCH-32.8* MCHC-37.4* RDW-13.8 Plt Ct-160
[**2181-5-22**] 07:05PM BLOOD Neuts-86.5* Lymphs-9.1* Monos-3.2 Eos-0.7
Baso-0.5
[**2181-6-18**] 05:06AM BLOOD Plt Ct-196
[**2181-6-15**] 12:57PM BLOOD PT-13.9* PTT-28.8 INR(PT)-1.2*
[**2181-5-20**] 06:20PM BLOOD PT-12.4 PTT-24.3 INR(PT)-1.0
[**2181-5-20**] 06:20PM BLOOD Plt Ct-160
[**2181-5-20**] 06:20PM BLOOD Fibrino-256
[**2181-6-7**] 05:27AM BLOOD Ret Aut-6.4*
[**2181-6-19**] 05:47AM BLOOD UreaN-20 Creat-1.2 Na-141 K-4.4 Cl-107
[**2181-5-20**] 06:20PM BLOOD UreaN-23* Creat-1.3*
[**2181-5-29**] 01:08AM BLOOD Glucose-92 UreaN-18 Creat-1.7* Na-141
K-3.9 Cl-105 HCO3-25 AnGap-15
[**2181-6-15**] 05:10AM BLOOD ALT-44* AST-23 AlkPhos-129 TotBili-0.2
[**2181-5-20**] 06:20PM BLOOD ALT-165* AST-131* LD(LDH)-609*
CK(CPK)-1193* AlkPhos-73 TotBili-0.7
[**2181-6-5**] 03:04AM BLOOD Lipase-177*
[**2181-5-29**] 07:20AM BLOOD Lipase-276* GGT-1046*
[**2181-6-1**] 06:42AM BLOOD CK-MB-3 cTropnT-0.04*
[**2181-5-20**] 06:20PM BLOOD cTropnT-0.18*
[**2181-5-20**] 06:20PM BLOOD CK-MB-15* MB Indx-1.3
[**2181-6-19**] 05:47AM BLOOD Mg-2.1
[**2181-5-20**] 09:16PM BLOOD Calcium-8.7 Phos-3.4 Mg-2.3
[**2181-6-7**] 05:27AM BLOOD calTIBC-290 Ferritn-941* TRF-223
[**2181-6-11**] 03:40PM BLOOD %HbA1c-5.4 eAG-108
[**2181-6-8**] 05:50AM BLOOD Triglyc-319* HDL-26 CHOL/HD-6.0
LDLcalc-66
[**2181-5-21**] 02:38PM BLOOD Triglyc-141 HDL-57 CHOL/HD-3.4
LDLcalc-108
[**2181-6-5**] 03:04AM BLOOD TSH-1.9
[**2181-5-25**] 02:44AM BLOOD Prolact-13
[**2181-5-20**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
sputum
GRAM STAIN (Final [**2181-5-23**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): TINY PLEOMORPHIC GRAM
NEGATIVE
COCCOBACILLI.
CONSISTENT WITH HAEMOPHILUS
SPECIES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2181-5-26**]):
SPARSE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Sinus rhythm. Possible old anterior wall myocardial infarction.
Possible old
inferior myocardial infarction. Compared to the previous tracing
there is no
change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 190 90 396/417 31 -24 14
Brief Hospital Course:
Mr. [**Known lastname 9579**] is a 47 year old male on [**2181-5-20**] while bike riding
had a cardiac arrest s/p AED shock with a complicated hospital
stay, initially admitted to OSH, then to the CCU for
continuation of cooling protocol.
Neuro: Seizure morning of [**5-25**], lasting about 10??????15 minutes. On
[**5-26**] EEG showed generalized slowing consistent with
encephalopathy or diffuse subcortical pathology. No focal
findings, no seizure activity. Repeat EEG on [**5-27**] no seizure
activity or epileptiform. CT head negative for intracranial
bleed. Phenytoin was used for seizure prophylaxis until his LFTs
trended upward. He was switched to Keppra on [**2181-6-3**]. He has
had no further seizure activity since [**5-24**]. Keppra 500 mg [**Hospital1 **]
will continue until seen by neurologist as an outpatient. Head
MRI [**2181-6-10**] with no acute infarctions. Throughout the rest of
his hospital course he was alert and oriented with no focal
deficits.
He was seen by Speech [**2181-6-12**] for absent memory of the day
before, day
of and several days after his arrest, but otherwise his short
and long term memory appear functional for tasks attempted
today. There are mild deficits in the area of working memory. He
underwent swallow evaluation preoperatively with strictions to
thin liquids and regular diet.
Physical therapy worked with him post operatively, and he was
cleared for discharge home
Respiratory: He was transferred from outside hospital intubated
and had prolonged intubation due to hypoxia related to
ventilator associated pneumonia. Preoperatively that was
resolved and remained extubated for multiple days prior to
surgery. Post operative cardiac surgery he was weaned and
extubated with in the first twenty four hours without
complications
Cardiac: He was transferred in from outside hospital after
witnessed cardiac arrest and defibrillated with AED, for
hypothermia cooling post arrest. He underwent cardiac
evaluation which included cardiac MRI which showed reversible
ischemia. He then underwent cardiac catheterization [**6-11**] that
revealed coronary artery disease and surgery was consulted. He
underwent coronary artery bypass graft surgery on [**6-15**]. He has
had no arrythmias postoperatively and remained stable.
GI: He received GI prophalaxis.
Renal: Baseline creatinine 1.1, elevated to 1.7 on [**5-29**] post
arrest acute kidney injury. His creatinine trended up and down
throughout admission but was back to 1.2 on discharge
ID: Treated preoperatively for Haemophilus influenza, ventilator
associated pneumonia with ten day course of meropenum and
vancomycin. Then he received vancomycin and cefazolin for
perioperative coverage.
Endocrine: insulin drip and then sliding scale utilized post
operatively for glucose management, preoperative HgbA1C 5.4 and
no history of diabetes.
Pain: Dilaudid and tylenol or post operative pain management
He was ready for discharge home with visiting nurse on hospital
day 31 and post operative day 4
Medications on Admission:
Lisinopril 40 mg daily
Atenolol 50mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours): around the clock for 5 days then change to as
needed .
7. ranitidine HCl 150 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 TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease s/p CABG
Ventilator associated pneumonia
Seizures
Cardiac arrest undetermined etiology
Normocytic anemia
Hypertension
Left ankle plating with subsequent plate removal
Discharge Condition:
Alert and oriented x3 nonfocal, anxious at times calms with
talking
Ambulating with steady gait
Incisional pain managed with Dilaudid and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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 [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2181-7-11**] 1:30
Cardiologist: Dr [**Last Name (STitle) 73**] [**Telephone/Fax (1) 62**] Date/Time:[**2181-7-12**] 2:00
Neurologist: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9580**] on [**8-15**] at 2:30pm
Wound check - cardiac surgery office [**Hospital **] medical building
[**6-27**] at 10:00am [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your
Primary Care Physician [**Last Name (NamePattern4) **] [**4-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2181-6-19**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,440
| 135,057
|
6647
|
Discharge summary
|
report
|
Admission Date: [**2165-1-12**] Discharge Date: [**2165-1-18**]
Date of Birth: [**2090-1-23**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 74 year old woman s/p Right total knee replacement in
[**1-17**] and MAC lung disease s/p R knee liner exchange and wash
out on [**12-3**], with intra-operative cultures growing
Streptococcus virdians on ceftriaxone (last day [**1-16**]), now
presenting with fever and hypotension. Patient states she has
had cough productive of yellow/white sputum x 2days. Denies sick
contacts. Had flu vaccine this year, denies myalgias. Fever to
101.5 this AM, which prompted her to present. +SOB and wheezing.
Denies dysuria, urgency, frequency. Denies abd pain/diarrhea
(last BM yesterday and formed). Also, her VNA thought that right
knee was warmer than previous, patient agrees. States that her
ROM has not been limited and that her pain in the right knee is
baseline.
Past Medical History:
- Mycobacterium avium intracellularae - treated for MAC from
[**2-/2157**] to [**7-/2158**]
- bronchiectasis
- Right total knee replacement [**2164-1-24**], on coumadin
- cholecystitis s/p cholecystectomy
- endometrial carcinoma s/p hysterectomy in [**10/2152**]
- Obstructive lung disease (FEV1/FVC 56 IN [**10-18**]), NOT on home 02
- Anxiety
Social History:
Retired, lives alone. Friend [**Name (NI) 1312**] has been staying with her
since her surgery. Her HCP is her sister. Smoked 1 pack/week x
20 years. Has not smoked for 25 years. She drinks 6-8 drinks per
week. Last drink 3 days ago. No history of withdrawl.
Family History:
colon cancer
Physical Exam:
PE on Admission:
General: Alert, oriented x 3, able to say months of year
backward, able to speak in full sentences but using accessory
muscles
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: wheezes throughout all lung fields, using accessory
muscles
CV: tachycardic rate, systolic murmur present (previously
documented)
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. R knee with no effusion, slight swelling, no
erythema/warmth, full ROM. Well healed scar. Unable to assess
for splinter hemorrhages given nailpolish.
Access: 3 PIV's (2 18gauges, 1 20gauge) and PICC (c/d/i/no
erythema or tenderness)
Pertinent Results:
Labs On Admission:
[**2165-1-11**] 10:30AM WBC-7.8 RBC-3.51* HGB-10.3* HCT-31.0* MCV-88
MCH-29.3 MCHC-33.1 RDW-14.5
[**2165-1-11**] 10:30AM UREA N-14 CREAT-0.7
[**2165-1-12**] 12:15PM PT-15.5* PTT-30.2 INR(PT)-1.4*
[**2165-1-12**] 12:15PM PLT COUNT-535*
[**2165-1-11**] 10:30AM CRP-19.0*
[**2165-1-12**] 12:15PM SED RATE-60*
.
Micro:
[**2165-1-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL
[**2165-1-12**] Influenza A/B by DFA DIRECT INFLUENZA A
ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL
INPATIENT
[**2165-1-12**] URINE Legionella Urinary Antigen -FINAL
[**2165-1-13**] WOUND CULTURE No Growth - FINAL
[**2165-1-14**] BLOOD CULTURE NGTD
[**2165-1-15**] BLOOD CULTURE NGTD
[**2165-1-16**] STOOL Cdiff NEGATIVE - FINAL
[**2165-1-14**] URINE CULTURE NEGATIVE - FINAL
[**2165-1-16**] 5:50 pm JOINT FLUID Source: Knee
GRAM STAIN (Final [**2165-1-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
[**2165-1-16**] 2:07 pm SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final [**2165-1-17**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
[**2165-1-15**] 4:29 pm STOOL **FINAL REPORT [**2165-1-17**]**
FECAL CULTURE (Final [**2165-1-17**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2165-1-17**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2165-1-16**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative)
.
Imaging:
Echo [**1-14**]: IMPRESSION: No echocardiographic evidence of
endocarditis. Normal regional and global biventricular systolic
function. Trace aortic and mitral regurgitation.
.
R knee xray [**1-12**]: IMPRESSION: No acute fracture or dislocation.
No evidence of hardware failure.
.
CXR [**1-13**] FINDINGS: As compared to the previous radiograph, there
is a newly appeared minimal right-sided pleural effusion.
Otherwise, the radiograph is unchanged, including the
pre-existing interstitial markings and the partial atelectasis
of the middle lobe. Unchanged size of the cardiac silhouette. No
newly appeared focal parenchymal opacities suggesting pneumonia.
.
CT chest without contrast [**1-16**]:
The heart is normal in size, with aortic valvular and mitral
annular calcifications noted. There is no pericardial effusion.
An aneurysm of the
ascending aorta measures 4.5 cm x 4.4 cm, previously measured
4.4 cm x 4.4 cm at a comparable level.
.
Central lymphadenopathy has increased, and is likely reactive. A
right upper paratracheal lymph node (2:18) measures 16 mm x 10
mm, previously measured 6 mm x 9 mm. A right paratracheal lymph
node measures 14 mm wide, previously 9 mm. A subcarinal node
measures 12 mm, previously 8 mm.
.
Widespread bronchiectasis and bronchial wall thickening, most
notable within the upper lobes and lingula, are associated with
numerous bronchiolar nodules and tree-in-[**Male First Name (un) 239**] opacities, which
are increased within the right lower lobe compared to the prior
study. There is also a new confluent opacification in the right
lower lobe (4:157-174). These findings progression of atypical
mycobacterial infection.
.
Chronic collapse of the right middle lobe is stable in
appearance. Mucoid
impaction within dilated bronchioles are notable within the
lingula.
.
A small non-hemorrhagic layering right pleural effusion is new.
.
This examination is not tailored for subdiaphragmatic
evaluation. The liver is diffusely low in attenuation,
compatible with fatty infiltration.
.
Osseous structures reveal no suspicious abnormality with
multilevel
degenerative changes of the spine seen.
.
IMPRESSION:
1. Interval worsening of diffuse airways disease, with a new
confluent area of opacification in the right lower lobe. The
findings are suggestive of atypical mycobacterial infection.
2. New small right pleural effusion.
3. Central lymphadenopathy, likely reactive.
4. Stable collapse of the right middle lobe.
5. Stable aneurysm of the ascending aorta.
Brief Hospital Course:
74 year old woman s/p R total knee replacement in [**1-17**] with R
knee liner exchange and wash out on [**2164-12-3**], with
intra-operative cultures growing Streptococcus virdians on
ceftriaxone who presented to the MICU with fever and
hypotension.
.
#. Presumed sepsis: Patient presented with hypotension to 70's
systolic in ED, improved to mid 80's to 90's systolic, MAPs 60's
following 4.5 liters IVF. Pt was admitted to the MICU out of
concern for sepsis, however pressors were not required. Highest
on differential included evolving sepsis due to combination of
fever, elevated WBC to 13, tachycardia, tachypnea (meeting
criteria for SIRS) plus suspected source of infection as PNA.
Patient was evaluated by the orthopedic team, who felt that her
R knee was a less likely source of recurrent infection. PICC
line was removed. The patient was started on Vancomycin and
Cefepime for HCAP, and levaquin for double coverage of
pseudomonas. Blood cultures were pending at the time of transfer
to the floor. Urine cultures were negative. ID consultation was
sought given the persistence of fever in the ICU. After her BPs
stabilized, she was called out to the medicine floor.
.
On the floor, the patient was noted to be normotensive
throughout her stay on the floor. All of her Cxs returned
negative (Blood, Urine, Sputum, catheter tip of PICC). As per
ID c/s, a CT chest was done which was concerning for progression
of [**Doctor First Name **], however pt's pulmonologist reviewed the films and felt
that this was not the case. The pt's knee was tapped by
Orthopedics and returned with no organisms on gram stain or Cx.
As we were happy to see the right knee did not seem to have an
active infx, we presumptively treated the pt for an HCAP for a 7
day course as that was thought to be the most likely source,
especially given the poor pulmonary substrate. Levofloxacin was
stopped after a 5 day course, and Vanc/Cefepime for 7 days as
noted above. The patient was prescribed Levoflox 750 mg PO
daily x 3 months for continued suppressive therapy of strep
viridans septic arthritis. Her leukocytosis also resolved. Of
note, the pt did develop diarrhea midway through her hospital
stay. C-diff was negative.
.
# Hypotension: See above for further details. In short, pt was
bolused with 4.5 L of NS in MICU, and became normotensive
without need for pressors. Lisinopril that pt is on as outpt
was stopped as pt remained normotensive. Most likely cause was
sepsis, and other causes were ruled out (eg: hemorrhage r/o with
stable Hct).
.
# Fever: See above for further details under "sepsis." Pt spiked
fever for first 3-4 days of hospitalization though
Vanc/Cefepime/Levo. Fevers stopped upon transfer to Medicine
Floor and remained afebrile for >48 hrs. Levo was dosed for 5
days, and Vanc/Cefepime for 7 days. Most likely cause was
infx/sepsis, and after all cxs negative, thought [**3-13**] HCAP. Also
on ddx is malignancy and rheumatologic process, however given
improvement with [**Last Name (LF) 621**], [**First Name3 (LF) **] defer further w/u for now and can be
reassessed as outpt if remaining concern.
.
# Tachypnea: Pt was tachypneic upon transfer to MICU, which
largely resolved after some ativan for anxiety. There was
thought for PE, however no right heart strain on EKG, and
satting well, also on home O2 of 2L. Out of concern that she
was a little volume up, she was diuresed with lasix x 1 which
helped her symptomatically. She was also continued on nebulizer
treatments for her underlying obstructive lung disease. Her
tachypnea did come and go on the medicine floor with unknown
etiology except for possible anxiety. ABGs were done to ensure
the pt was not acidotic and that she was not retaining CO2
beyond respiratory compensation for her apparent metabolic
alkalosis.
.
# History of Mycobacterium avium intracellularae - treated for
MAC from [**2-/2157**] to 06/[**2158**]. Repeat CT as above was originally
concerning for progressive [**Doctor First Name **], however Dr. [**Last Name (STitle) **], her
pulmonologist did not feel this was the case. This combined
with her bronchiectasis does give her a poor pulmonary substrate
that we feel contributed to the most likely HCAP causing her
septic presentation. We did sent AFB Cxs (which were negative
preliminarily) and also sent mycolytic blood cxs, which were
negative/pending at time of discharge.
.
# ? Vaginal bleeding/hematuria: Pt is s/p TAH-BSO, and without
pelvic pain. Per pt, recently saw GYN at [**Hospital1 112**] and usually uses
vagifem and evista at home, which was recently stopped. No
bleeding now. We were unable to prescribe these medications as
they are nonformulary, and the pt declined pursuing this issue
further. her bleeding resolved after 1 day.
.
# H/o Right total knee replacement [**2164-1-24**], c/b infx 2 months
ago. As above, orthopedics did not feel it was infected, and
our exam is definitely underwhelming for a septic picture.
Nonetheless, given the foreign body after her TKR, she was still
tapped by orthopedics and we were reassured that there was no
active infx (WBC of 6500, no organisms on gram stain). She
still requires long term [**Month/Day/Year 621**] for the previous septic arthritis
and was discharged on 3 months of Levofloxacin 750 mg PO daily.
.
# Anemia: long standing issue and pt is on iron supplementation
at home. Iron labs were again sent during this hospitalization
and were c/w Fe-deficiency anemia. iron supplementation was
started in house and she was discharged back on her home
regimen.
# Endometrial carcinoma s/p hysterectomy in [**10/2152**]: Stable per
pt, and is followed by GYN at [**Hospital1 112**]. She recently saw her GYN
within the last 2 weeks per the pt and was told things were
fine.
.
# Anxiety: Pt was continued on her home ativan regimen
.
# HTN: holding lisinopril in setting of hypotension. She
remained normotensive at the time of discharge, so the
lisinopril was held and she will readdress this as an
outpatient.
Medications on Admission:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. Lantus 100 unit/mL Solution Sig: Twenty Eight (28) units
Subcutaneous at bedtime.
6. Humalog 100 unit/mL Solution Sig: Per sliding scale units
Subcutaneous four times a day: Please resume your home insulin
sliding scale.
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain for 4 days.
(Patient states NOT taking)
9. acetaminophen 500 mg Capsule Sig: [**2-11**] Capsules PO four times
a day as needed for pain.
(Patient states NOT taking)
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
2. clobetasol 0.05 % Cream Topical
3. desonide Topical
4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
5. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. raloxifene 60 mg Tablet Sig: One (1) Tablet PO once a day.
9. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for insomnia.
10. Vitamin B Complex Oral
11. calcium Oral
12. ergocalciferol (vitamin D2) Oral
13. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day. Tablet(s)
14. biotin 1 mg Tablet Sig: One (1) Tablet PO once a day.
15. Ultram 50 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for pain.
16. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
17. Exelderm 1 % Cream Sig: small application application
Topical once a day: for nails.
18. ketoconazole 2 % Cream Sig: small application Topical once a
day: to affected areas.
19. Vagifem 10 mcg Tablet Sig: 2.5 tablets Vaginal twice weekly
for Wednesday and Sunday days: insert intravaginally on Mon and
[**Last Name (un) **].
20. finasteride 1 mg Tablet Sig: One (1) Tablet PO once a day.
21. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
22. Home oxygen
Please apply 2 liters continuously pulse dose for portability.
Diagnosis - COPD
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY:
1. sepsis, felt to be hospital acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization. You were admitted to the ICU at [**Hospital1 18**] for
fevers. Your CT scan was reviewed by Dr. [**Last Name (STitle) **] and it was felt
that your [**Doctor First Name **] infection was stable. However, you met with the ID
doctors, and your fevers were felt to be related to a pneumonia.
You were treated with fluids and antibiotics. To rule out
infection in the knee, fluid was withdrawn from your right knee.
This was not suggestive of infection. You completed 7 days of
antibiotics for pneumonia. Per discussion with the ID doctors,
for your prior knee infection, you will now continue oral
levofloxacin. Your blood pressures have been fine without your
prinivil (lisinopril), so do not take this until your doctors
[**Name5 (PTitle) **] [**Name5 (PTitle) **] to start it.
.
MEDICATION CHANGES:
- START levofloxacin 750 mg daily for 3 months
- STOP LISINOPRIL
.
Please continue your other medications as prescribed. Please
follow-up with your doctors as noted below.
Followup Instructions:
Department: ORTHOPEDICS
When: FRIDAY [**2165-1-18**] at 12:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ORTHOPEDICS
When: FRIDAY [**2165-1-18**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2165-1-25**] at 9:00 AM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Name: [**Last Name (LF) 903**],[**First Name3 (LF) 251**] J.
Location: [**Hospital6 9657**] MEDICAL GROUP
Address: [**Location (un) **], [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 24396**]
Appointment: Tuesday [**1-22**] at 2:40PM
.
Name: [**Last Name (LF) 903**],[**First Name3 (LF) 251**] J.
Location: [**Hospital6 9657**] MEDICAL GROUP
Address: [**Location (un) **], [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 24396**]
Appointment: Tuesday [**1-22**] at 2:40PM
Please speak with Dr. [**Last Name (STitle) **] about setting up outpatient
PFTs (Pulmonary Function Tests).
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2165-1-19**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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icd9pcs
|
[
[
[]
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286, 292
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15593, 15593
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|
3629, 6690
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81,416
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47715
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Discharge summary
|
report
|
Admission Date: [**2100-11-4**] Discharge Date: [**2100-11-23**]
Date of Birth: [**2034-7-13**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Confusion, rash and fever.
Major Surgical or Invasive Procedure:
Lumbar puncture, twice.
History of Present Illness:
This is a 66 year old woman with recent diagnosis of HIV/AIDS
on HAART, last CD4 count 253 and, depression and mild dementia,
who presented from home with a vesicular rash, confusion and
fevers on the [**4-4**]. She was admitted to medicine.
Mrs. [**Known lastname 100760**] was in her usual state of health approximately one
week before admission. Her husband has noticed for the past [**3-17**]
days she has seemed more confused than normal. At the same time
she has developed a right sided vesicular rash, located over her
right breast. The rash was painful and mildly pruritic. She had
had mild fevers at home to as high as 100.1 without chills. She
had not had headache, photophobia or neck stiffness. Nor had she
chest pain or difficulty breathing. No nausea, vomiting,
adominal pain, diarrhea, constipation, dysuria, hematuria, leg
pain or swelling. She did have decreased PO intake for the past
week. She did have one episode of urinary incontinence which is
unusual for her and no episodes of bowel incontinence. She was
seen by her VNA on the day of presentation who noted her to be
mildly confused with a temperature of 100.1. Her primary care
physician was [**Name (NI) 653**] who recommended transfer to the
emergency room.
In the ED, initial vs were: T: 102 BP: 136/75 P: 85 R: 16 O2:
100% on RA. She had a CXR which showed a possible small left
lower lobe opacity. She had a head CT without acute changes. EKG
showed normal sinus rhythm, normal axis, normal intervals, small
q waves in III, avF, poor baseline tracing but no acute ST
segment changes, no change from prior dated [**2100-6-24**]. She had a
lumbar puncture which showed 18 WBC in tube 4 with 16 RBC, 61%
neutrophils. Protein was 62, glucose 66. She received
ceftriaxone 2 grams IV x 1 and azithromycin 500 mg PO x 1. She
weas admitted to the floor for further workup.
Past Medical History:
1. Diabetes mellitus - diet controlled.
2. History of cutaneous T-cell lymphoma - quiescent after UV
light treatment.
3. Hospitalized at [**Location (un) 511**] [**Hospital **] Hospital in [**2087**] for
psychotic depression.
4. Hospitalized at [**Hospital 1263**] Hospital in [**2098**] for depression (with
psychotic features) - in remission and controlled with
mirtazipine, aripiprazole.
5. Question of mild cognitive impairment prior to HIV diagnosis.
6. HIV - diagnosed after presenting with pneumocystic pneumonia
in [**2100-6-14**]. Last negative test [**2087**]. Possible occupational
exposure (unclear). CD4 count at diagnosis 60, started on HAART
with good response (see below).
Social History:
From [**State 9512**], college in [**State 33977**]. Separated from husband
[**Doctor Last Name **] [**Telephone/Fax (1) 100761**] cell). Has a daughter who lives in
[**State 9512**]. Worked in [**Hospital1 18**] micro lab as medical technician since
[**2066**]. Reports occupational exposures. No h/o smoking,
excessive alcohol drinking or illicit drug use.
Family History:
Adult onset DM in both parents. Father with possible depression.
Colon CA in brother who died of it at 67; heart disease in one
brother. [**Name (NI) **] breast cancer.
Physical Exam:
Initial examination on arrival on the [**Hospital1 **]
Vitals: T: 99.5 BP: 154/85 P: 86 R: 18 O2: 100% on RA
General: Cachectic, somolent but arrousable, oriented x 3, no
acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.
Exam on re-admission to floor (from ICU)
Vitals: T: 99.6 BP: 134/86 P: 79 R: 18 O2: 100% on RA
General: Cachectic, slightly withdrawn with little spontaneous
behavior, oriented x 3, no acute distress
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: Supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic blowing
murmur loudest at upper left sternal edge, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.
Neurological: Mentation is slow and there is a poverty of speech
and movement. Affect is flat. Oriented to person, place and
time. Decreased 4/5 strength on left side in UMN pattern: paucy
of finger movement which is slow and clumsy; RUE WNL. Tone
decreased in lower extremities and surprisingly depressed
reflexes in the lower extremities. Tone lower in legs. Unable
to walk at present and needs walker at baseline.
Exam on discharge:
VS: T 98.8 BP 126/73 HR 91 RR 18 O2 Sat 98% RA
Gen: cachectic-appearing, in NAD. MMM. No thrush.
Neck: supple, trachea midline, no LAD, no JVD
Lungs: CTAB, no evidence of accessory muscle use
COR: RRR, no n/g/r
Abd: soft, non-tender. No h/s/m.
BACK: no CVAT.
SKIN: faint erythematous macular rashes of various shape and
sizes on cheeks, trunk, and limbs. No vesicle or ulcer.
Musculoskeletal: Decreased range of motion in lower extremities.
Neuro: Mental status: alert, oriented to person and place.
Intermittently oriented to year. Knows president is [**Last Name (un) 2753**]. Says
that her colleague came to see her today (on the day of
discharge). "[**Doctor First Name **] had swine flu!" Took 3 trials to learn
objects. Recalled [**1-16**] objects without hint. Recalled 2nd object
with a hint. Did not recall 3rd object with hint. Could not
complete days of week backwards, though she occasionally is able
to. Able to name pen and pen-cap. Able to repeat "no ifs, ands,
or buts." Followed 2-step command. Answered questions
appropriately, with some delay, improved. CN: PERRL, EOM
intact, visual fields intact, facial sensation intact, tongue
protrudes midline. I, VIII, visual acuity not evaluated
specifically. Sensation: intact to touch and temperature in both
upper and lower extremities. Strength: Increased tone in upper
and lower extremities. Hip flexion [**4-18**], hip extension not
evaluated. Right leg extension [**3-18**]. Left leg extension [**4-18**]. Leg
flexion [**3-18**]. Plantar flexion [**4-18**]. Dorsiflexion [**3-18**]. Upper
extremity strength 4/5. Patient able to sit up from supine to 40
degrees without assistance. Able to prop herself up on her arms.
Able to sit up in chair without props. Finger-to-nose intact.
DTR exam deferred. Unable to walk at present.
Pertinent Results:
Laboratory data at admission
Blood studies:
[**2100-11-4**] 02:00PM BLOOD WBC-4.0 RBC-3.47* Hgb-9.3* Hct-27.9*
MCV-80* MCH-26.8* MCHC-33.3 RDW-15.0 Plt Ct-207
[**2100-11-4**] 02:00PM BLOOD Neuts-65.7 Lymphs-25.9 Monos-7.1 Eos-0.4
Baso-0.9
[**2100-11-4**] 02:00PM BLOOD Plt Ct-207
[**2100-11-4**] 02:00PM BLOOD PT-12.5 PTT-26.6 INR(PT)-1.1
[**2100-11-4**] 02:00PM BLOOD Glucose-131* UreaN-14 Creat-1.1 Na-133
K-4.2 Cl-99 HCO3-25 AnGap-13
[**2100-11-5**] 08:05AM BLOOD ALT-22 AST-31 AlkPhos-76
[**2100-11-5**] 08:05AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.7 Mg-1.9
[**2100-11-5**] 08:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2100-11-4**] 02:10PM BLOOD Lactate-1.5
Crytococcal antigen - Negative
HIV-1 Viral Load/Ultrasensitive (Final [**2100-11-12**]): 177 copies/ml.
Urine studies:
[**2100-11-4**] 03:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2100-11-4**] 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
CSF studies:
[**2100-11-4**] 07:24PM CEREBROSPINAL FLUID (CSF) WBC-18 RBC-16*
Polys-61 Lymphs-28 Monos-0 Eos-1 Atyps-1 Macroph-9
[**2100-11-4**] 07:24PM CEREBROSPINAL FLUID (CSF) TotProt-62*
Glucose-66
CYTOMEGALOVIRUS - Negative
PCR HERPES SIMPLEX VIRUS - Negative
PCR [**Male First Name (un) 2326**] VIRUS (JCV) - Negative
TOXOPLASMA GONDII BY PCR - Negative
VARICELLA DNA (PCR) VDRL - Positive
VDRL - Negative
Laboratory data at discharge:
[**2100-11-23**] 06:36AM BLOOD WBC-5.1 RBC-2.81* Hgb-7.6* Hct-22.4*
MCV-80* MCH-26.9* MCHC-33.7 RDW-16.1* Plt Ct-447*
[**2100-11-20**] 06:50AM BLOOD Neuts-78.9* Lymphs-14.0* Monos-2.3
Eos-4.7* Baso-0.2
[**2100-11-23**] 06:36AM BLOOD Plt Ct-447*
[**2100-11-23**] 06:36AM BLOOD PT-13.2 PTT-33.4 INR(PT)-1.1
[**2100-11-23**] 06:36AM BLOOD Glucose-112* UreaN-6 Creat-0.8 Na-141
K-4.1 Cl-103 HCO3-30 AnGap-12
[**2100-11-23**] 06:36AM BLOOD ALT-36 AST-39 LD(LDH)-342* AlkPhos-100
TotBili-1.3
[**2100-11-22**] 05:01AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
Other studies (pertinent only):
MRI head (with and without contrast):
Mild brain atrophy and mild medial temporal atrophy and mild
changes of small vessel disease. These findings are unchanged
from previous MRI of [**2100-6-20**]. No enhancing brain lesions are
seen.
MRI spine (with and without contrast):
No abnormal signal is seen within the spinal cord or extrinsic
compression identified, nor there is evidence of abnormal
enhancement. No significant change is seen since [**2100-11-11**].
Degenerative changes.
EMG ([**2100-11-12**]):
Limited study. There is no electrophysiologic evidence for a
generalized polyneuropathy affecting large-diameter nerve
fibers. There is no evidence of ongoing denervation suggestive
of a neurogenic process. Poor muscle activation, likely
secondary to a central nervous system process, prevents accurate
diagnosis or exclusion of a myopathy or radiculopathy.
Portable chest x-ray ([**2100-11-17**]):
Left PICC line shows a normal course and terminates in the right
atrium, withdraw the catheter to 3 cm for standard positioning.
No complications related to the procedure.
EKG ([**2100-11-4**]):
Artifact is present. Sinus rhythm. There is a late transition
with Q waves in the anterior leads consistent with probable
prior anterior myocardial infarction. Low voltage in the
precordial leads. Compared to the previous tracing low voltage
is new.
Brief Hospital Course:
Summary
Ms. [**Known lastname 100760**] presents with single dermatomal herpes zoster with
concurrent CNS herpes zoster infection, manifesting as a
meningoencephalitis (confirmed by pleocytosis and elevated
protein level in CSF, VZV PCR positive in CSF, and positive VZV
DFA from scrapings of vesicular rashes in the right T3
dermatome), in the context of HIV/AIDS. Tests for other causes
including seizure, TB, fungi, HSV, HTLV, CMV, JCV, T. pallidum
were negative. Varicella zoster virus infection was treated
with intravenous acyclovir resulting in the resolution of mental
status changes and a return to baseline over cognitive function
over the two weeks following admission. She will now need some
intensive physical therapy to restore the function of her legs.
Acyclovir therapy will continue until she follows up with
Neurology, Dr. [**Last Name (STitle) 2340**], on the [**7-1**]. Dr. [**Last Name (STitle) 2340**]
will perform lumbar puncture at that time to repeat CSF VZV PCR.
Chronology
Ms. [**Known lastname 100760**] was initially admitted to the floor, where she was
initially somnolent but alert and oriented, but became less
responsive over the course of the day. Repeat CSF on the floor
showed 133 with 69% PMNs, protein 114 and glucose 54, concerning
for evolving meningoencephalitis. Brain MR w/wo contrast was
obtained, per Neurology recommendations, and showed no
abnormalities. The patient was transferred to the [**Hospital Unit Name 153**] for
further care.
In the [**Hospital Unit Name 153**], antibiotic treatment continued that included
empiric treatment for bacterial or viral meningitis with
acyclovir, ceftriaxone, amoxicillin, and vancomycin. She was
noted to have hyperreflexia and spasticity on exam. Her mental
status improved over the course of her ICU stay. She was alert,
responsive to voice commands, able to answer simple questions.
Upon becoming more stable she was returned to the floor.
Brief Hospital Course by Problem
Meningoencephalitis and Mental Status Changes
Given fever, confusion and lumbar puncture findings, viral and
other non-bacterial meningoencephalitides were considered most
likely early in the stay. Numerous other processes were
excluded as summarized above and these phenomena were attributed
to CNS VZV infection. This was also considered most likely
given concomitant Shingles. As can sometimes occur in the
context of HIV, Ms. [**Known lastname 100760**] suffered from a diffuse and
generalized encephalitis as a result of this infection. This
has been successfully treated with high-dose intravenous
acyclovir. Mental status appears to have returned to
pre-admission character with some residual lower extremity
weakness (as discussed below).
Given her gradual deterioration prior to admission, we also
consider it likely that AIDS dementia complex may have been
present, that has possibly partially responded to HAART.
Herpes Zoster rash
The patient had a vesicular rash over her right breast, classic
in appearance for zoster; her direct antigen test was positive
for VZV and negative for HSV. Acyclovir was given throughout
the admission. The rash resolved over about ten days. Analgesia
was given cautiously given her mental status and our concern for
masking fever. Low doses of opioids were used.
HIV/AIDS
Ms. [**Known lastname 100760**] was recently diagnosed with HIV/AIDS in [**6-/2100**] when
she presented with PCP pneumonia, most recent CD4 count 253.
She was continued on her antiretroviral therapy consisting of
Norvir, Reyataz and Truvada. She was continued on Bactrim for
and azithromycin prophylaxis.
Depression with psychotic features
Given the resolution of her mental status changes, we can now
see that it is unlikely that depression contributed to these
changes. Nonetheless, psychiatry was consulted while she was an
inpatient. Abilify was reduced from 20 to 10 mg at night
because of concern that this may have contributed to mental
status changes.
Elevated PTT - excessive response to heparin
The patient was initially placed on subcutaneous heparin for
DVT prophylaxis. After a couple of days on the subcutaneous
heparin, her PTT was noted to be elevated at 150, and her PT and
INR were also elevated. Recheck of her coags showed that they
were down-trending, and they had returned to [**Location 213**] levels by
the evening.
The patient was placed on pneumoboots for DVT prophylaxis. It
appears that she does not have an allergy to heparin, but
responded in excess of expectation. We advise caution with
further use (lower dose and monitor PTT).
Rash
She developed an erythematous rash with confluent plaques on
the arms, legs, chest, and back, sparing the mucous membranes,
consistent with a drug reaction. This appeared two weeks after
admission. Dermatology were consulted and thought the reaction
most consistent with cephalosporins rather than acyclovir.
Given this impression and the importance of acyclovir in
treatment, acyclovir was continued and the rash treated with
fexofenadine, famotidine, and triamcinolone ointment. The rash
resolved while acyclovir was continued supporting the above
impression.
Lower Extremity Weakness
Despite improvements in mental status, the patient continued
to have lower extremity weakness of unknown etiology. An MRI
and EMG were performed to evaluate for cord compression, other
intrathecal process, radiculopathy or polyneuropathy without
identifying a cause. Her lower extremity weakness is improving
with her mental status, suggesting that this was a result of
encephalitis. She has developed some degree of contracture in
the lower extremities and intermittently complains of joint
aches. Physical therapy has worked with her to help improve her
range of motion.
Nutrition
Feeding has also recovered with the recovery of baseline
mental status. Feeding had been an issue with poor PO intake.
The patient and her husband have declined replacement of a
Dobbhoff feeding tube, and she required 1:1 assistance with
meals of ground solids. PO intake continues to improve, and
patient has started to feed herself.
Anemia
Likely contributions include reduced nutritive intake for part
of the admission, the present illness and HIV. No source of
blood loss, no evidence of hemolysis.
Joint Pain
Likely due to osteoarthritis and immobility.
Diabetes Mellitus
Stable with small doses (two units) of Humalog by sliding
scale on occasion.
Medications on Admission:
Abilify 20 mg, 1 tablet, PO daily
Mirtazapine 15 mg, 1 tablet PO HS
Multivitamin, one capsule PO daily
Norvir 100 mg, one capsule PO daily
Reyataz 150 mg, 2 capsules PO daily
Trimethoprim-Sulfamethoxazole 400 mg- 80 mg, 1 tablet PO daily
Truvada 200 mg- 300 mg, 1 tablet PO daily
Zithromax, 2 tablets PO weekly
Discharge Medications:
1. Acyclovir Sodium 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours).
2. Insulin sliding scale
Humalog 2 units has sometimes been required before lunch or
dinner.
3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO once a day.
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Reyataz 300 mg Capsule Sig: One (1) Capsule PO once a day.
7. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
8. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(FR).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Skin rash: Please continue
while rash is present. Likely to only be required for another
few days after discharge. .
11. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**]
Discharge Diagnosis:
Primary diagnoses
Varicella zoster virus rash (shingles)
Varicella zoster virus meningoencephalitis.
Secondary diagnoses:
Dementia
Hypertension
HIV
Depression
Diabetes, type II
Drug reaction - rash
Osteoarthritis
Anemia
Drug rash
Discharge Condition:
mental status now at baseline; lower extremity weakness,
improving
Stable, mental status at baseline. Lower extremity weakness
improving.
Discharge Instructions:
You were seen at [**Hospital1 18**] for varicella zoster virus
meningoencephalitis (viral infection with inflammation of the
brain and membranes surrounding it) and shingles (varicella
zoster virus rash). We have been treating you with acyclovir, to
treat this infection, greatly impoving your mental status, lower
body weakness, and rash.
Please continue to take all of your prescribed medications, as
directed. Your medications have changed. Please note new
medications and/or old medications with NEW doses.
ACYCLOVIR- 500 mg IV every 8 hours
LISINOPRIL- 5 mg by mouth at bedtime
ABILIFY- NEW dose- 10 mg by mouth daily
We did not change your HIV medications. Please continue to take
NORVIR 100 mg by mouth daily, REYATAZ 2 capsules by mouth daily,
TRUVADA 200mg-300mg by mouth daily.
Please keep all of your follow-up appointments.
If you get a fever of 100.4, chills, nausea, vomiting, your
symptoms do not improve or if they worsen, please return to the
hospital for evaluation.
Followup Instructions:
Please follow-up with:
Provider: [**Name10 (NameIs) 2341**] [**Name11 (NameIs) **], Neurologist and HIV specialist. Your
appointment is on [**2100-12-1**] at 2:00 PM. MD Phone: ([**Telephone/Fax (1) 100762**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:([**Telephone/Fax (1) 6732**]
Date/Time:[**2100-12-3**] 11:30
Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) 26**] [**Name8 (MD) 30125**], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2100-12-14**] 2:20
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
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76,078
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14268
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Discharge summary
|
report
|
Admission Date: [**2155-6-10**] Discharge Date: [**2155-6-19**]
Date of Birth: [**2078-3-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
decreased responsiveness, leukocytosis
Major Surgical or Invasive Procedure:
Bedside debridment of sacral decub
History of Present Illness:
Pt is a 77 year old Male with history of parkinson's disease,
h/o multiple CVAs, CAD who presented to ED with decreased
responsiveness, fevers and leukocytosis. He lives at home and
family and caregivers noted decreased responsiveness for the
past 4 days or so. He had a quarter sized sacral decubitus ulcer
which has rapidly expanded over the past 2 weeks with increased
eschar. He has been declining over the past year and his current
baseline is responsive with blinks and hand signals, but over
the past few days, mostly today he has been non-communicative.
Also with fevers, some tachypnea and darker urine. He was seen
by his PCP 4 days ago who started an antibiotic for a
leukocytosis, repeat blood work returned with a markedly
elevated WBC count for which the PCP recommended the patient be
brought to the emergency room. He presented to the ED, at that
time his VS: 99.7 105/62 92 18 90% RA, while in ED his temp went
as high as 101.4, BP as low as 86/47. He had labs notable for
acute renal failure with hyponatremia and hyperkalemia, as well
as a leukocytosis to 26.8 with 97%N, stable thrombocytosis and
hematocrit of 30.5. His INR was elevated at 8.3 and lactate
elevated to 3.0. His UA was positive. CXR prelim read showed no
infiltrate. He was given vanc and zosyn. His ECG showed no
evidence of peaked t-waves for K of 6.1, he was given
kayexelate, bicarb, insulin and glucose. At the time of transfer
his VS: 99.1 83 92/54 24 94% RA.
On arrival to the floor pt was non-responsive to voice,
minimally reponsive to stimuli. ROS unobtainable. Team engaged
in lengthy meeting with wife reviewing prognosis, she confirmed
that the patient was full code.
Past Medical History:
1. R MCA proximal CVA [**2-19**] @ [**Hospital1 2025**] (received tPA)
2. Parkinson's disease f/b B+ W neurologist (Dr. [**Last Name (STitle) 42389**];
responded well to Sinemet after diagnosis of PD ([**9-/2152**]) was
made, has been declining steadily over the past year.
3. Diverticulosis
4. h/o left MCA stroke in [**6-/2151**]; stroke was thought to be
embolic, although no embolic source was found; he was started on
Aggrenox and baby ASA. [**Name2 (NI) **] long-lasting effects from the stroke;
initial symptons were a fall. By the time that he was evaluated,
he had recovered. He had a little bit of an aphasia.
5. HTN
6. Coronary artery disease s/p MIs [**Numeric Identifier 42390**], s/p angioplasty;
7. GERD
8. Essential thrombocytopenia on hydroxyurea
9. Osteopenia
10. Hyperlipidemia
11. Postural tremor
12. h/o nephrolithiasis
Social History:
Lives at home; 2 home health aides. Stays on counter-pulsation
bed. Married, no tobacco, occasional EtOH.
Family History:
Brother with [**Name2 (NI) 499**] cancer
Physical Exam:
Vitals: T:98.6 BP:88/54 P:78 R:19 SaO2: 98% Ra
General: Frail, cachectic, elderly man, does not respond to
voice, occasional moaning with repositioning.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP, copius secretions
Neck:In neck pillow, tortocollis to right. Neck veins seen to
7cm Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or
rales, unusual respiratory rhythm
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted. PEG tube in place, c/d/i.
Extremities: Cachectic, no edema, in multipodus boots,
contractures of upper and lower extremities. 10x8x2" foul
smelling sacral decubitus ulcer, tracks 2.5 cm at one point.
Partially covered by black eschar.
Skin: no rashes or lesions noted.
Neurologic: EOMI. Does not respond to voice, intermittent
moaning with movement/stimuli.
Pertinent Results:
[**2155-6-10**] 02:35PM BLOOD WBC-26.8*# RBC-3.03* Hgb-9.7* Hct-30.5*
MCV-101* MCH-32.1* MCHC-31.9 RDW-16.6* Plt Ct-873*
[**2155-6-11**] 04:00AM BLOOD WBC-24.7* RBC-2.69* Hgb-8.9* Hct-27.3*
MCV-101* MCH-33.0* MCHC-32.5 RDW-17.5* Plt Ct-801*
[**2155-6-12**] 03:48AM BLOOD WBC-20.6* RBC-2.51* Hgb-8.2* Hct-25.7*
MCV-102* MCH-32.8* MCHC-32.1 RDW-17.0* Plt Ct-767*
[**2155-6-13**] 07:36AM BLOOD WBC-21.4* RBC-2.25* Hgb-7.5* Hct-23.6*
MCV-105* MCH-33.3* MCHC-31.7 RDW-17.5* Plt Ct-777*
[**2155-6-14**] 06:30AM BLOOD WBC-16.3* RBC-2.31* Hgb-7.7* Hct-23.6*
MCV-102* MCH-33.2* MCHC-32.6 RDW-17.0* Plt Ct-685*
[**2155-6-10**] 02:35PM BLOOD Neuts-97.2* Lymphs-1.7* Monos-0.7*
Eos-0.4 Baso-0.1
[**2155-6-11**] 04:00AM BLOOD Neuts-94.3* Bands-0 Lymphs-3.0*
Monos-1.9* Eos-0.8 Baso-0.1
[**2155-6-12**] 03:48AM BLOOD Neuts-94.7* Lymphs-3.7* Monos-1.3*
Eos-0.1 Baso-0.1
[**2155-6-11**] 04:00AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-1+
Schisto-1+ Burr-1+ Tear Dr[**Last Name (STitle) **]1+
[**2155-6-14**] 06:30AM BLOOD Plt Ct-685*
[**2155-6-14**] 06:30AM BLOOD PT-18.5* PTT-31.6 INR(PT)-1.7*
[**2155-6-13**] 07:36AM BLOOD PT-24.8* PTT-33.5 INR(PT)-2.4*
[**2155-6-12**] 03:48AM BLOOD PT-34.1* PTT-40.1* INR(PT)-3.6*
[**2155-6-11**] 04:00AM BLOOD PT-59.6* PTT-53.4* INR(PT)-7.1*
[**2155-6-10**] 05:30PM BLOOD PT-68.1* PTT-45.9* INR(PT)-8.3*
[**2155-6-14**] 06:30AM BLOOD Glucose-135* UreaN-83* Creat-1.7* Na-140
K-3.6 Cl-108 HCO3-20* AnGap-16
[**2155-6-12**] 03:48AM BLOOD Glucose-171* UreaN-100* Creat-1.9*
Na-130* K-3.4 Cl-98 HCO3-20* AnGap-15
[**2155-6-11**] 04:00AM BLOOD Glucose-123* UreaN-107* Creat-2.0*
Na-122* K-3.9 Cl-94* HCO3-20* AnGap-12
[**2155-6-10**] 04:30PM BLOOD Glucose-116* UreaN-121* Creat-2.5*
Na-116* K-6.1* Cl-81* HCO3-20* AnGap-21*
[**2155-6-10**] 02:35PM BLOOD Glucose-147* UreaN-125* Creat-2.5*#
Na-115* K-5.3* Cl-83* HCO3-17* AnGap-20
[**2155-6-14**] 06:30AM BLOOD ALT-34 AST-86* AlkPhos-172* TotBili-0.8
[**2155-6-13**] 07:36AM BLOOD ALT-45* AST-159* LD(LDH)-289*
AlkPhos-236* TotBili-0.7
[**2155-6-12**] 03:48AM BLOOD ALT-32 AST-201* LD(LDH)-218 AlkPhos-251*
TotBili-0.7
[**2155-6-11**] 04:00AM BLOOD ALT-46* AST-384* LD(LDH)-293*
AlkPhos-344* TotBili-0.5
[**2155-6-14**] 06:30AM BLOOD Albumin-2.0* Calcium-7.7* Phos-3.6 Mg-2.1
[**2155-6-14**] 06:30AM BLOOD Albumin-2.0* Calcium-7.7* Phos-3.6 Mg-2.1
[**2155-6-12**] 03:48AM BLOOD Albumin-2.1* Calcium-7.2* Phos-4.8*
Mg-2.3
[**2155-6-10**] 05:30PM BLOOD Albumin-2.6* Calcium-7.9* Phos-4.8*
Mg-2.4
[**2155-6-11**] 04:00AM BLOOD calTIBC-185* VitB12-1733* Folate-14.3
Ferritn-518* TRF-142*
[**2155-6-12**] 03:48AM BLOOD Vanco-21.7*
[**2155-6-10**] 03:20PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.013
[**2155-6-10**] 03:20PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2155-6-10**] 03:20PM URINE RBC-21-50* WBC->50 Bacteri-MANY
Yeast-NONE Epi-0-2 TransE-[**4-17**]
[**2155-6-10**] 1:25 pm BLOOD CULTURE SOURCE: VENIPUNCTURE.
Blood Culture, Routine (Preliminary):
ANAEROBIC GRAM NEGATIVE ROD(S). BETA LACTAMASE
POSITIVE.
GRAM POSITIVE RODS.
Anaerobic Bottle Gram Stain (Final [**2155-6-11**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE ROD(S).
[**2155-6-10**] 3:20 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2155-6-12**]**
URINE CULTURE (Final [**2155-6-12**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2155-6-10**] 11:06 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2155-6-11**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2155-6-11**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
CHEST (SINGLE VIEW) Study Date of [**2155-6-10**] 3:28 PM
IMPRESSION:
1. No acute cardiopulmonary process.
2. Left 9th rib posterolateral old rib fracture, accurate age
indeterminant.
Correlate with physical exam.
Brief Hospital Course:
1. Septic Shock, bactremia, Septicemia (Gram +), severe
Leukocytosis, Bacterial UTI:
Although no obvious source was identified for such an
inflammatory response, the most obvious sources are urine which
grew out sensitive klebsiella and the massive sacral ulcer. No
evidence of pulmonary infection based on CXR or respiratory
status. Per wife no recent diarrhea concerning for c. diff but
c-diff toxin assay was negative.
- As speciation of agents was an extended period and there the
sepsis was severe, the decision was made to treat broadly with
antibiotics to cover GNRs, anearobes and staphylococcus with
vancomycin/zosyn (renally dosed) which was ultimately
transitioned to unasyn IV after discussion with the ID team. A
PICC line was placed for this indication.
-agressive fluid hydration for early goal directed therapy,
bolus prn for SBP <100, UOP <30 or elevated lactate.
- Patient initially treated in ICU, then managed on the floor
2. Acute renal failure:
- No prior labs since [**2153**], but at that time, baseline
creatinine 0.9-1.1. Given likely infection, ARF probably
represents pre-renal physiology vs ATN from hypotension/Shock,
or much less likey AIN from recent antibiotics use.
- Agressive hydration
- improved slowly during the admission
- All medications were renally dosed
3. Masive Sacral Decubitus ulcer:
- Has rapidly enlarged over past 2 weeks despite wound care at
home, now with foul odor, purulent discharge and large eschar,
does appear to track, unclear if goes to bone. Unclear if
patient's recent decompensation is due to ulcer or other
infection, would expect pt to be less stable if he had osteo
with associated bacteremia.
- Kinair bed was obtained as wound was markedly moist
- plastic surgery debrided at bedside once, waited for INR to
decrease for further debridment, which was repeated when the INR
was 1.7 on [**6-14**]. Post procedure the patient had moderate bleeding
which was contained with a pressure dressing. Plastic surgery
was consulted again, and sutures were placed for hemostasis.
[**Hospital1 **] chemical debridement was recommended for ongoing wound care.
Pt. required the transfusion of a total of 4 units of PRBC for
correction of acute blood loss anemia. Tubefeedings were
adjusted to optimize nutrition and aid in wound healing.
4. Bacterial UTI:
- UA with WBC, bacteria, blood, leukesterase.
- Cultures grew out klebsiella, which was sensitive to zosyn,
however, more so to unasyn. Plan total course of abx. therapy
of 14 days.
- possible source of sepsis, but unlikely to be sole source, as
wound contamination may have contributed.
5. Hyponatremia:
- Initially admitted with extremely low sodium, so unclear if
occult seizures were present, however this was rapidly corrected
in the ICU above the danger zone.
- Likely hypovolemic hyponatremia, however despite return to
euvolemia his sodium remained low, so nutrition was reconsulted
to calculate a new free-water regimine with his tube feeds. With
the new regimen his sodium corrected to normal on [**6-14**]
-hydration overnight --> improved with hydration; pt. ultimately
slightly hypernatremic with change to concentrated TF, so this
was adjusted back prior to discharge.
6. Hyperkalemia:
- In setting of ARF. No peaked Ts on ECG. Got kayexelate,
insulin, bicarb in ED.
- This corrected while still in the ICU
7. Essential thrombocytosis:
- hydroxyurea was cointinued
- His coumadin was held for coagulopathy, as the risk of
bleeding from debridement was higher than thrombosis risk. His
platelets were lower than his baseline likely due to shock -
these remained relatively stable throughout the admission.
8. Anemia of acute blood loss (at wound debridement) - managed
with blood transfusions. [**Month (only) 116**] require ongoing aranesp as an
outpatient (to follow up with his hematologists).
9. Coagulopathy:
On coumadin for h/o stroke and essential thrombocytosis. Likely
elevated in setting of nutritional deficiency combined with
recent antibiotic use and hepatic dysfunction from shock liver.
- monitor for bleeding
- held coumadin until INR <2, can be restarted once no evidence
of ongoing bleeding.
10. Severe Malnutrition
- Nutrition consultation was obtained
- Tube feeds were continued, although this markedly is impairing
wound healing
11. CAD:
- No ischemia on ECG
- Continue ASA, statin
- Beta-blocker was held in setting of possible sepsis.
12. Transaminitis
- This was most likely shock liver, although an occult gallstone
certainly could have been present, which would have explained
the initial shock as cholangitis, but would have passed prior to
his arrival, as this improved steadily over his stay
13. Parkinson's Disease:
- continued sinemet, methylphenidate
## Prophylaxis: Heparin SC 5000 tid
## Code status: DO NOT RESUSCUTATE FOR PULSELESS ARREST (no
compressions or shocks) - whould want intubation for respiratory
arrest/distress. Many discussions had with with wife and with
palliative care - family wishes are for pt. to be maintained
until [**Hospital1 **] graduations in several weeks after which time
consideration of palliative approach will be readdressed.
Medications on Admission:
Coumadin 2mg
Sinemet 25/100 2 tabs TID
Fosomax 70mg QFriday
Asa 81mg daily
Prevacid 30mg daily
Colace 100mg [**Hospital1 **]
Metoprolol 12.5mg [**Hospital1 **]
Citracal 2 tabs [**Hospital1 **]
Vitamin C 500mg daily
lipitor 80mg daily
Hydroxyurea 1000mg alternating with 500mg daily
Senna 2 tabs QHS
Miralax 17grams daily
Ritalin 5mg [**Hospital1 **]
Keppra 750mg [**Hospital1 **]
Flonase 1 spray NU daily
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO
TID (3 times a day).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day): hold for loose stools.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five Hundred Four (504) mg
PO DAILY (Daily): via g tube.
5. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
7. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: 750 mg PO BID (2 times
a day).
8. Fluticasone 50 mcg/Actuation Spray, Suspension [**Last Name (STitle) **]: One (1)
Spray Nasal DAILY (Daily).
9. Hydroxyurea 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day): pt alternates 500 mg and 1000 mg
doses on alternating days.
10. Hydroxyurea 500 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO EVERY
OTHER DAY (Every Other Day).
11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
12. Methylphenidate 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2
times a day).
13. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Age over 90 **]: 300 mg
PO DAILY (Daily).
14. Nystatin 100,000 unit/mL Suspension [**Age over 90 **]: Ten (10) ML PO TID
(3 times a day): to be applied then suctioned out.
15. Zinc Sulfate 220 mg Capsule [**Age over 90 **]: One (1) Capsule PO DAILY
(Daily).
16. Collagenase 250 unit/g Ointment [**Age over 90 **]: One (1) Appl Topical
twice a day: to wound bed.
17. Polyethylene Glycol 3350 100 % Powder [**Age over 90 **]: Seventeen (17)
grams PO DAILY (Daily) as needed for Constipation.
18. Ampicillin-Sulbactam 1.5 gram Recon Soln [**Age over 90 **]: 1.5 grams
Injection Q6H (every 6 hours) for 5 days.
19. Aspirin 81 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet, Chewable
PO once a day: can resume once there is no further evidence of
bleeding at sacral wound bed.
20. Coumadin 2 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day: can
resume as secondary stroke prophylaxis only once there is no
evidence of ongoing bleeding at the sacral wound (as with
aspirin). Goal INR [**3-18**]. Titrate to this once resumed.
21. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day (3) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Septic Shock
Septicemia Gram Positive Cocci
Bactremia
Bacterial UTI
Transaminitis
Stage 4 Sacral Decubitus Ulcer
Coagulopathy
Acute Renal Failure
Hyponatremia, then hypernatremia
Severe Malnutrition
Discharge Condition:
stable
Discharge Instructions:
He should be turned multiple times daily to prevent worsening of
the ulcer
Pt. requires Q 2 hour mouth care with suctioning to prevent
aspiration/mucous plugging
His coumadin and aspirin have been held given bleeding from site
of wound debridement - see med list for instructions on
resumption.
Hospice care should be entertained again following goal of pt.
surviving to [**Hospital1 **] graduation
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 42391**] - call to discuss need for follow
up care and or initiation of hospice care as family deems
appropriate.
Wife [**Name (NI) 2048**] will discuss need for follow up with pt.s
hematologist.
|
[
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"038.3",
"707.03",
"V12.54",
"276.52",
"285.1",
"570",
"261",
"E878.8",
"332.0",
"584.5",
"V44.1",
"276.1",
"530.81",
"276.0",
"238.71",
"785.52",
"286.7",
"414.01",
"412",
"707.24",
"041.3",
"995.92",
"998.11",
"599.0",
"276.7",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
17094, 17160
|
8722, 13864
|
354, 390
|
17403, 17412
|
4078, 7106
|
17862, 18129
|
3095, 3137
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14322, 17071
|
17181, 17382
|
13890, 14297
|
17436, 17839
|
3152, 4059
|
7150, 8699
|
276, 316
|
418, 2087
|
2109, 2955
|
2971, 3079
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,333
| 106,091
|
27616
|
Discharge summary
|
report
|
Admission Date: [**2120-12-11**] Discharge Date: [**2120-12-14**]
Date of Birth: [**2050-5-12**] Sex: M
Service: MEDICINE
Allergies:
Wellbutrin / Oxycontin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 67472**] is a 70 year-old gentleman w/ Stage IV NSCLC
metastatic to brain/spine/kidneys, s/p cycle 3 of [**Doctor Last Name **]/taxol
(last [**2120-12-10**]), also with h/o emphysema on 2L home O2, PE on
lovenox, now presenting after he developed a fever overnight. He
felt nauseous as per usual after chemotherapy but felt more weak
and feverish last night, checked temp and was was 101.7, for
which he took two tylenol and defervesced. He also had a an
episode of N/V which improved with Zofran x 1. He had no
increase in his baseline shortness of breath or cough. No
abdominal pain, ongoing N/V, or diarrhea. This AM however, he
had an episode of urinary incontinence and had fever again. He
then presented to the ER.
.
In the ED: V/S 97.1 92 107/90 96%. PE with left basilar crackles
(stable), blanching erythema ? contact dermatitis in groin. Labs
revealed lactate 3.0, WBC 10.9 with 95% PMNs. Spiked in the ER.
CXR showed no obvious infiltrate. EKG showed low voltage
nonspecific TWF in V4-V6, TWI V3. nl axis, nl intervals. U/A
WNL. BPs dropped to the 80s He received vancomycin, cefepime,
tylenol, zofran, 10mg IV dexamethasone, and 4 L IVF. A CVL was
placed. His pressures normalized and he did not requires
pressors. He was then admitted to the [**Hospital Unit Name 153**]. Most recent VS:
100/54 88 21 98%4L.
.
Currently, . ROS is positive for admission to [**Hospital1 18**] [**2039-11-16**] for
shortness of breath which was attributed to pneumonia, treated
with a 7 day course of levofloxacin. Prior to this he had fever,
congestion, and cough x 1 week, given a 5-day course of
azithromycin for presumed URI/bronchitis. He has chronic DOE
with only walking a few steps, and overall fatigue and malaise.
He denies any chest pain, calf pain or leg swelling. He reports
+productive cough yellow sputum, +nasal congestion. +nausea this
morning. He denies any sick contacts, hemoptysis, hoarseness,
headaches, sore throat, vomiting, abdominal pain, diarrhea,
BRBPR, dysuria or back pain. On further questioning patient also
reports difficulty with ambulation the past few days and
lightheadedness. He denies any vertigo or focal weakness or
numbness of the extremities. He denies any back pain, urinary or
stool incontinence. Patient states he feels unsteady while he
walks and that he has been feeling very weak as well.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Stage IV Non-Small Cell Lung Cancer, s/p Cycle 2 [**Doctor Last Name **]/Taxol
s/p whole brain irradiation
.
PAST MEDICAL HISTORY:
====================
Diabetes Mellitus Type 2
Hx of Pulmonary Embolus on Lovenox
Emphysema
Asbestosis
Right rectus sheath hematoma, [**2-26**] spontaneous coughing in [**Month (only) **]
[**2117**]
Left adrenal adenoma
Small sliding hiatal hernia
Bilateral pleural plaques
Social History:
Mr. [**Known lastname 67473**] is married and lives with his wife.
His daughter [**Name (NI) **] is a [**Hospital1 18**] ER nurse and lives next door. He
used
to work in a navy yard for a year in [**2074**], where he was exposed
to asbestos. He retired 15 years ago from a middle management
position in a defense company. Tobacco: He smoked [**1-26**] PPD x 50
yrs and has tried to quit several times. The last time he quit
was on [**2120-8-22**]. He drinks two beers a day and denies
having
any history of alcohol abuse. He denies illicit drug use
Family History:
His mother died from [**Name (NI) 5895**] disease and his
father had mesothelioma and died at age 58 from a heart attack.
His father worked in a shipyard which was believed to be a
contributing factor to his cancer. His paternal grandfather
also
died from lung cancer and used to work in the coal yards. He
has
one brother who is healthy and one sister, age 63 who has
cervical cancer. He has two daughters who are healthy.
Physical Exam:
GENERAL: pleasant elderly gentleman sitting up in bed in NAD
SKIN: WWP, + erythematous blanching pruritic papular rash in
inguinal area and underneath elastic underwear band c/w
candidiasis vs. folliculitis
HEENT: EOMI, PERRLA, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: +crackles at bilateral bases L>R, decreased breath sound
at bilateral bases, +mild expiratory rhonchi L base
ABDOMEN: soft, ND +BS, NT, no rebound/guarding
EXT: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP, PT, popliteal, radial, carotid pulses bilaterally
NEURO: A&Ox3 CN II-XII grossly intact and symmetric B/L; +some
resting tremor of B/L UE most pronounced in hand/fingers; no
asterixis; 2+ patellar and biceps reflexes B/L; 5/5 strength UE
flex/ext, 4+/5 LLE hip and knee extensors, [**5-28**] LLE hip/knee
flexors, [**5-28**] dorsiflexion and plantarflexion B/L; 5/5 strength
RUE & RLE finger to nose intact, downgoing toes B/L, gait not
assessed.
Pertinent Results:
.
Micro:
GRAM STAIN (Final [**2120-12-12**]):
[**11-17**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): YEAST(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2120-12-15**]):
SPARSE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
.
[**2120-12-11**] 11:50PM CORTISOL-23.8*
[**2120-12-11**] 10:51PM GLUCOSE-197* UREA N-13 CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-18* ANION GAP-12
[**2120-12-11**] 10:51PM CALCIUM-6.6* PHOSPHATE-2.6* MAGNESIUM-1.7
[**2120-12-11**] 10:51PM CORTISOL-8.4
[**2120-12-11**] 10:51PM WBC-7.1 RBC-2.72* HGB-8.6* HCT-26.6* MCV-98
MCH-31.6 MCHC-32.3 RDW-18.6*
[**2120-12-11**] 10:51PM NEUTS-95.3* LYMPHS-2.5* MONOS-1.8* EOS-0.3
BASOS-0.1
[**2120-12-11**] 10:51PM PLT COUNT-240
[**2120-12-11**] 10:51PM PT-17.1* PTT-70.1* INR(PT)-1.5*
[**2120-12-11**] 06:29PM TEMP-37.1 PO2-75* PCO2-36 PH-7.33* TOTAL
CO2-20* BASE XS--6 INTUBATED-NOT INTUBA
[**2120-12-11**] 06:29PM LACTATE-1.4
[**2120-12-11**] 05:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2120-12-11**] 05:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2120-12-11**] 05:55PM URINE RBC-0-2 WBC-[**3-28**] BACTERIA-RARE YEAST-NONE
EPI-0
[**2120-12-11**] 05:55PM URINE GRANULAR-0-2 HYALINE-[**3-28**]*
[**2120-12-11**] 11:42AM COMMENTS-GREEN TOP
[**2120-12-11**] 11:42AM LACTATE-3.0*
[**2120-12-11**] 11:30AM GLUCOSE-151* UREA N-14 CREAT-1.4* SODIUM-138
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-18* ANION GAP-20
[**2120-12-14**] 06:40AM BLOOD WBC-3.9* RBC-3.10* Hgb-9.6* Hct-29.3*
MCV-95 MCH-31.0 MCHC-32.8 RDW-18.4* Plt Ct-217
[**2120-12-14**] 06:40AM BLOOD Neuts-84.6* Lymphs-11.7* Monos-1.9*
Eos-1.8 Baso-0.1
[**2120-12-14**] 06:40AM BLOOD Plt Ct-217
[**2120-12-14**] 06:40AM BLOOD Glucose-107* UreaN-6 Creat-0.9 Na-140
K-3.9 Cl-109* HCO3-22 AnGap-13.
.
[**2120-12-13**].MR HEAD W & W/O CONTRAST
.
IMPRESSION:
.
1. Minimal increase in the right cerebellar lesion; minimal-mild
decrease in the size of the right frontal parasagittal lesion.
No obvious new lesions within the limitations of motion
artifacts.
2. Extensive paranasal sinus disease as well as mucosal
thickening/fluid in the mastoid air cells on both sides. New
since the prior study.
.
IMPRESSION: [**2120-12-11**]
UPRIGHT AP VIEW OF THE CHEST:
Again, there is a large mass overlying the left hilum,
consistent with
findings from prior chest radiographs and CT exam from [**11-26**], [**2120**],
consistent with the patient's history of lung cancer. The heart
size is
normal and stable. Multiple smaller pulmonary nodules throughout
the lungs
are unchanged in appearance. Stable mild opacification along the
left base,
most likely representing atelectasis. There are no new focal
consolidations
seen. There is no pneumothorax. There is mild blunting of the
right
costophrenic angle, which may represent a small pleural
effusion. There is an
old right rib deformity, seen on prior CT exam.
Brief Hospital Course:
70 year old male with hx of non small cell lung cancer, s/p
cycle 3 [**Doctor Last Name **]/taxol on [**2120-11-12**] presenting with fevers, cough,
SOB found to have likely PNA based on symptoms and infiltrate.
.
# Fever - He was febrile on presentation to the ED raising
concern for infection given WBC count, fever, and elevated
lactate. He presented with cough however his CXR was equivocal
for a PNA. No clinical concern for sepsis as one episode of
hypotension in ED likely [**2-26**] volume depletion given poor PO
intake. He was given broad spectrum antibiotics with
vanc/levo/cefepime. Pt not neutropenic. He was DFA negative,
legionella negative, [**Last Name (un) 104**] stim test was within normal limits.
He was discharged on cefpodoxime and azithromycin for a total
antibiotic course of 14 days.
.
# # NSCLC: He has known brain metastases and was s/p cycle 3
[**Doctor Last Name **]/taxol and was not neutropenic on presentation. MRI head
showed minimal increase in the right cerebellar lesion;
minimal-mild decrease in the size of the right frontal
parasagittal lesion. No obvious new lesions within the
limitations of motion artifacts. Future plan from oncologic
perspective to be made as outpatient.
He continued to take keppra, prophylactic bactrim and
dexamthasone which was increased during his hospitalization from
1mg to 4mg daily.
.
# DM2
-Metformin was held during his hospitalization, and he resumed
taking this medication on discharge.
.
# [**Last Name (un) **]: On presentation his creatinine was Cr 1.4 from 1.1;
likely secondary to volume depletion. He received IVF boluses
with rapid correction of his creatinine which was within normal
limits at the time of discharge.
#. h/o PE: he continued to receive lovenox
Medications on Admission:
1. Acetaminophen 650 mg PO q6h PRN pain
2. Enoxaparin 60 mg/0.6 mL SC q12h
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Levetiracetam 1000mg PO BID
5. Omeprazole 20 mg PO daily
6. Bactrim 160-800 mg 1 tab 3x wk (M,W,F)
7. home Oxygen Sig: Two (2) continuous: 2L nasal cannula
continuous, pulse dose for portability.
8. Dexamethasone 1 mg PO daily.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. sertraline 50mg once daily
Discharge Medications:
1. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
2. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1)
10ml dose PO once a day.
Disp:*30 doses* Refills:*2*
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): do not exceed 3000mg/day.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
14. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea: Do not drink alcohol or perform
activities that require a fast reaction time. [**Month (only) 116**] cause
sedation.
Disp:*90 Tablet(s)* Refills:*0*
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary
Pneumonia
Secondary
Non small cell lung cancer
Discharge Condition:
stable, good
Discharge Instructions:
You were admitted to the hospital because you were having
fevers.
You were found to have a pneumonia and this was treated with
antibiotics.
.
We ADDED Zofran 8mg dissolvable tablet every 8 hours as needed
for nausea
We ADDED cefpodoxime 200mg every 12 hours for 10 days
We ADDED azithromycin 250mg daily for 10 days
We ADDED ativan 0.5 mg every 8 hours as needed for nausea
We ADDED megace 400mg daily
We ADDED dexamethasone 4mg daily
.
Please return to the hospital or call your doctor if you
experience any shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, headache, fever,
chills, night sweats, muscle aches, joint aches, light
headedness, fainting, blood in your stool, blood in your urine,
or any other problems that are concerning to you.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2120-12-16**]
11:55
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2120-12-16**]
2:00
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2120-12-24**] 9:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"486",
"250.00",
"492.8",
"593.9",
"501",
"227.0",
"787.01",
"162.3",
"276.50",
"311",
"198.3",
"787.91",
"198.0",
"553.3",
"V12.51",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12792, 12843
|
8693, 10442
|
291, 297
|
12943, 12958
|
5246, 8670
|
13792, 14292
|
3745, 4174
|
11030, 12769
|
12864, 12922
|
10468, 11007
|
12982, 13769
|
4189, 5227
|
246, 253
|
325, 2682
|
2882, 3157
|
3173, 3729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,845
| 165,860
|
23012
|
Discharge summary
|
report
|
Admission Date: [**2189-2-4**] Discharge Date: [**2189-2-6**]
Date of Birth: [**2116-12-30**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
aphasia episodes, transfer from OSH
Major Surgical or Invasive Procedure:
CT
History of Present Illness:
72 yo RH man with h/o HTN, s/p pacemaker placement,
hypercholesterol who was in his USOH until about 5pm today when
while shopping with his grandson he noted all of a sudden he was
unable to "get words out." He could understand others and knew
what he wanted to say but was unable to say it. No visual
changes, no weakness, or numbness. These sx lasted 15 min then
resolved. He drove himself home. At home, his daughter became
worried and she urged him to go to hospital. He presented to
[**Last Name (un) 4068**] where head CT was performed and showed a small left
temporal/parietal bleed (at 6:51pm today). While transferring
from one bed to another at OSH, he re-experienced another
transient episode of word expression difficulty, quickly
resolved. BP was 201/89 at OSH, started on nipride drip.
Transferred to [**Hospital1 18**] for neurosurgical eval. No Nsurg
intervention to be done per Nsurg eval.
Patient has had a frontal dull "behind the eyes" headache x 2-3
days, of which he attributed it to sinus problems. His sinus
problems include symptoms of burning behind his nose. 2 nights
ago he noted the ceiling fan moving (or he was moving) but he
just went to bed and the sensation went away. + chills x 3 days
but no fever, night sweats. No CP, palp, SOB, abd pain, emesis,
blood in stools or urine. He has had years of urinary
dysfunction (mainly frequency that awakens him q 2 hours at
night), s/p extensive workup with dx of "nonspecific urinary
dysfunction."
Past Medical History:
1. HTN - was high in the 170's at last PCP [**Name Initial (PRE) **] 2 weeks ago,
attributed to anxiety
2. hypercholesterolemia
3. s/p pacemaker for 'skipped beats' [**2188-1-21**], Dr.
[**Last Name (STitle) 43421**]
4. anxiety
5. nonspecific urinary dysfunction as above
6. Bilateral deafness
7. h/o bells palsy on the left [**6-/2187**]
Social History:
Married, lives with wife, retired cleaner/gardener, quit
tob [**2163**] (former 1.5ppd for several years), etoh drink q 3 weeks
(infrequent). No drugs.
Family History:
brother with a "stroke" at age 60, also had CABG
Physical Exam:
VITALS: no temp, 149/81, 100, 95% RA, RR 20's
GEN: no acute distress, pleasant
SKIN: keloid scar over right PM placement
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple, no carotid bruits, no LAD
CHEST: normal respiratory pattern, CTA bilat
CV: regular rate and rhythm without murmurs
ABD: soft, nontender, nondistended, +BS, no HSM
EXTREM: no edema
NEURO:
Mental status:
Patient is alert, awake, pleasant affect.
Oriented to person, place, time and president.
Good attention.
Language is fluent with good comprehension, repitition.
Occasional paraphasic errors, says "Gear" instead of ear. mild
"Pa" sound difficulty.
No apraxia, agnosias, no neglect. No right/left mismatch.
Registration [**4-9**] objects. Recalls [**4-9**] objects after 3 minutes.
Cranial Nerves:
I: deferred
II: Visual acuity: not tested. Visual fields: full to
left/right/upper/lower fields. Fundoscopic exam: unable to
visualize . Pupils: 3->2 mm, consenual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or
ptosis.
V: facial sensation intact over V1/2/3 to light touch and pin
prick. Jaw closing strengh normal.
VII: right lower face droop
VIII: hearing intact to fingers rubbing on pillow cases
IX, X: abnormal labial but normal lingual/gutteral sounds.
Symmetric elevation of palate.
[**Doctor First Name 81**]: SCM and trapezius [**6-11**] bilaterally
XII: tongue midline without atrophy or fasciulations.
Sensory:
Normal touch, vibration, proprioception, pinprick sensation.
Motor:
Normal bulk, tone. No fasciculations or drift. No adventitious
movements. No asterixis.
Strength:
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF Toe
RT: 5 5 5 5 5 5 5 5 5 5 5 5 5
LEFT:5 5 5 5 5 5 5 5 5 5 5 5 5
Reflexes:
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 2 2 2 3 2 down
LEFT: 2 2 2 3 2 down
Coordination:
Normal finger-to-nose, RAMs.
Gait: not tested as BP elevated
Pertinent Results:
[**2189-2-6**] 06:55AM BLOOD WBC-9.7 RBC-4.44* Hgb-13.9* Hct-40.8
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.5 Plt Ct-181
[**2189-2-6**] 06:55AM BLOOD Plt Ct-181
[**2189-2-5**] 03:00AM BLOOD PT-13.4 PTT-28.7 INR(PT)-1.1
[**2189-2-6**] 06:55AM BLOOD Glucose-94 UreaN-10 Creat-0.9 Na-143
K-3.6 Cl-104 HCO3-31* AnGap-12
[**2189-2-6**] 06:55AM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.5 Mg-2.5
[**2189-2-6**] 06:55AM BLOOD Phenyto-14.0
EKG: V-paced
NCHCT: 1. No change in the left intraparenchymal hemorrhage.
Given its location, amyloid angiopathy or underlying hemorrhagic
lesion are considerations. This is not the typical location for
hypertensive hemorrhage.
2) Chronic microvascular infarctions.
CT angio: results pending.
Brief Hospital Course:
72 yo man with left small temporal/parietal parynchymal bleed.
He presents with paroxysmal episodes of transient aphasia,
likely secondary to seizures. Exam is significant for right
face droop and mild paraphasia. Etiology of bleed is likely
amyloid. (Cannot get MRI secondary to pacemaker).
Regarding hospitalization course, patient was initially managed
on labetolol drip in ICU as his SBP was in the 200's at OSH, and
140's here at [**Hospital1 18**]. His blood pressure was well controlled and
he was transitioned to a PO regimen of calcium channel blocker
and ace inhibitor. NCHCT was unchanged from OSH. CT angio
showed normal blood vessels.
He was loaded on dilantin and maintained on 100mg TID. Phenytoin
level on day of discharge was 14.
He was continued on lipitor for high cholesterol.
PPx: SC heparin, PPI
Followup: with PCP and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of stroke clinic.
Medications on Admission:
norvasc 5mg daily
lipitor 20mg daily
ativan prn anxiety
hydrocortisone top for keloid over pacemaker
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left temporal parietal brain hemorrhage
2. Aphasic episodes likely secondary to seizure activity
Discharge Condition:
Stable. Cleared by PT by discharge home. Neurologically intact
other than right facial weakness.
Discharge Instructions:
Please return to the emergency room if you experience any severe
headaches, dizziness, incoordination, numbness, weakness, or
word finding difficulties.
[**State 350**] state law is such that you should not operate a
motor vehicle for 6 months after having a seizure.
Followup Instructions:
Please call your primary care physician in order to schedule a
follow up appointment within the next 1-2 weeks.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital 4038**] Clinic in 3
months. You should continue taking the Dilantin until your
follow up appointment. Call [**Telephone/Fax (1) 44**] to schedule an
appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"780.39",
"300.00",
"784.3",
"272.0",
"401.9",
"V45.01",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6750, 6756
|
5230, 6171
|
350, 354
|
6900, 6998
|
4491, 5207
|
7315, 7796
|
2427, 2478
|
6323, 6727
|
6777, 6879
|
6197, 6300
|
7022, 7292
|
2493, 2859
|
275, 312
|
382, 1871
|
3273, 4472
|
2874, 3257
|
1893, 2240
|
2256, 2411
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,515
| 191,807
|
2871
|
Discharge summary
|
report
|
Admission Date: [**2178-9-28**] Discharge Date: [**2178-10-4**]
Date of Birth: [**2113-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy x 2
History of Present Illness:
65 y/o M h/o Afib on outpatient coumadin, CAD s/p LAD stent, s/p
gastric bypass [**4-27**], & morbid obesity admitted to MICU [**9-28**] with
BRBPR. AM of admission, noted 3 bloody BM with associated
lightheadedness and dizziness. He called PCP who referred pt to
ED. He denied pain with BM, abdominal pain, N/V, f/c, CP, SOB,
palpitations. No prior h/o GIB.
.
In ED, T98.3, HR64, BP 112/palp, RR 16, O2sat 100% RA. Soon
after, HR 150's, BP 91/48. EKG showed AFib with RVR. NGL
non-diagnostic. INR 2.1, HCT 33.7 initially (baseline 33-35). He
received 2U PRBC but Hct 33 -> 30. Another 2U PRBC, 2 bags
platelets, FFP, Vitamin K 10 mg given. Transfered to MICU. A
PICC line was placed [**9-30**].
.
Patient required total of 5U PRBC total. [**9-29**] colonoscopy
revealed a large amount of old & new blood throughout. [**9-29**]
tagged RBC scan was negative for a source of bleeding. [**10-1**]
repeat colonoscopy revealed diverticulosis but no active bleed.
He was transferred to the medical floor for further management.
Past Medical History:
1. CAD s/p proximal LAD stent ([**2172**])
2. CVA x2 with left-sided weakness
3. AFib
4. Morbid obesity
5. Recurrent cellulitis
6. Chronic lymphedema
7. Hypertension
8. Hypercholesterolemia
9. Obstructive sleep apnea on CPAP
10. OA - knees
11. s/p gastric bypass [**2175-4-25**]
12. s/p Lap cholecystectomy
[**83**]. s/p appendectomy
Social History:
Lives with wife and son. Volunteers at [**Location (un) **] Veterans Assoc.
Ambulates with cane at baseline. Smokes [**2-26**] cigars daily, no
ETOH/IVDU.
Family History:
No known h/o GIB or colon CA
Physical Exam:
V/S: T97.3 HR 71 BP 104/52 RR 14 O2sat 100% RA
GEN: Pleasant, alert obese gentleman in NAD
HEENT: NC/AT PERRL EOMI conj. pale sclera anicteric OP clear w/
MMM
NECK: supple; no JVD, LAD
PULM: CTAB no w/r/r
CV: irreg irreg no m/r/g
ABD: obese soft NTND normoactive BS no HSM but difficult to
assess [**12-26**] habitus
EXT: WWP 1+ PP chronic lymphedematous changes bilat R medial
calf erythema no warmth, tenderness; no c/c
NEURO: A+Ox3; 5/5 strength throughout
Pertinent Results:
[**2178-9-28**] 11:35PM GLUCOSE-83 UREA N-15 CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-24 ANION GAP-11
[**2178-9-28**] 11:35PM CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-1.9
[**2178-9-28**] 11:35PM WBC-4.3 RBC-3.24* HGB-9.5* HCT-28.4* MCV-88
MCH-29.5 MCHC-33.6 RDW-15.0
[**2178-9-28**] 11:35PM PLT COUNT-108*
[**2178-9-28**] 11:35PM PT-16.1* PTT-28.9 INR(PT)-1.5*
[**2178-9-28**] 05:14PM HGB-10.1* calcHCT-30
[**2178-9-28**] 10:35AM HGB-10.7* calcHCT-32
[**2178-9-28**] 10:30AM GLUCOSE-132* UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16
[**2178-9-28**] 10:30AM estGFR-Using this
[**2178-9-28**] 10:30AM CK(CPK)-83
[**2178-9-28**] 10:30AM CK-MB-5 cTropnT-<0.01
[**2178-9-28**] 10:30AM WBC-4.8 RBC-3.70* HGB-11.0* HCT-33.3* MCV-90
MCH-29.7 MCHC-33.0 RDW-15.3
[**2178-9-28**] 10:30AM NEUTS-79.7* LYMPHS-15.2* MONOS-3.6 EOS-0.7
BASOS-0.8
[**2178-9-28**] 10:30AM PLT COUNT-134*
[**2178-9-28**] 10:30AM PT-21.8* PTT-29.4 INR(PT)-2.1*
.
[**2178-9-29**] GI bleeding study
IMPRESSION: No bleeding site identified.
.
[**2178-10-2**] Unremarkable upper GI series/small bowel follow-through
in this patient status post Roux-en-Y gastric bypass
Brief Hospital Course:
#BRBPR - Immediately upon presentation, 2 large bore IV's were
placed, and aggressive IVF resuscitation was begun. The patient
was typed & crossed, and transferred to the MICU for close
monitoring. Hematocrit on admission was 33.3% and was monitored
every 8 hours. Hct nadir was 27.6% on HD#3. He required a total
of 5 U PRBC. His coagulopathy was reversed with FFP and Vitamin
K. Colonoscopy on HD#2 revealed a large amount of old & new
blood throughout the colon. Tagged RBC bleeding scan on HD#2 was
negative for a source of bleeding. Repeat colonoscopy on HD#4
revealed diverticulosis but no active bleeding. The working
diagnosis was diverticular bleed. Symptoms had resolved on HD#4
and the patient was stable for transfer to the medical floor.
Because of a large amount of cecal blood seen on the second
colonoscopy, an upper GI series/small bowel follow-through was
performed on HD#5, which was unremarkable. The patient's
hematocrit remained stable HD#[**2-28**] and he did not require any
more transfusions. He was instructed to follow up with his PCP
immediately following discharge.
.
# RLE erythema - Because of a history of recurrent cellulitis,
the patient was begun on IV vancomycin upon admission.
Antibiotic was administered through a LUE PICC line after
placement was confirmed by x-ray, as the patient had poor
peripheral IV access. Upon transfer to the medical floor, the
patient denied fever or chills and erythema of the RLE had
markedly improved, without warmth or tenderness. Vancomycin was
discontinued on HD#5 as these skin changes were felt to be more
consistent with chronic lymphedema. His PICC was removed prior
to discharge.
.
# AFib - The patient was monitored on telemetry. His coumadin
was held in the setting of GIB. His dose of lopressor on
admission on 12.5 mg PO BID. Frequent episodes of AFib with RVR
to the 130s required gradual uptitration of the lopressor dose
to 75 mg PO TID. The patient was discharged on Toprol XL 225 mg
PO daily. GI was consulted regarding restarting coumadin prior
to discharge, and it was decided that coumadin would be held
pending follow-up with the patient's PCP [**Name Initial (PRE) 176**] 1 week of
discharge.
.
# CAD s/p LAD stent - ASA was held in the setting of GIB.
Lopressor was continued as above.
.
# Chronic lymphedema - Lasix was held in the setting of
hypovolemia and mild hemodynamic instability on admission, but
was resumed prior to discharge when the patient's condition had
markedly improved.
.
# F/E/N - The patient remained NPO for procedures during the
first 3 days of admission. When bleeding had resolved, he was
started on a clear liquid diet which was advanced to a regular
diet. The patient tolerated this well prior to discharge.
Electrolytes were monitored daily and repleted as needed.
.
# PPx - The patient was given twice daily intravenous PPI in the
setting of GIB. He was given pneumatic boots and SQH for DVT
prophylaxis.
Medications on Admission:
ASPIRIN 81 mg daily
FUROSEMIDE 20 MG daily
METOPROLOL 12.5 mg [**Hospital1 **]
Warfarin 7.5 mg daily
Atorvastatin 10 mg daily
MULTIVITAMINS
NITROGLYCERIN 10MG (0.4MG/HR)-- Apply 8 in the evening and
remove
at 8 a.m.
VITAMIN B-12 500 mcg daily
Fluticasone 50 mcg--1-2 puffs intranasal QD
.
ALLERGIES: NKDA
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1) Lower gastrointestinal bleed
2) Atrial fibrillation
Secondary diagnoses:
1. CAD s/p proximal LAD stent ([**2172**])
2. CVA x2 with left-sided weakness
3. AFib
4. Morbid obesity
5. Recurrent cellulitis
6. Chronic lymphedema
7. Hypertension
8. Hypercholesterolemia
9. Obstructive sleep apnea on CPAP
10. OA - knees
11. s/p gastric bypass [**2175-4-25**]
12. s/p Lap cholecystectomy
[**83**]. s/p appendectomy
Discharge Condition:
Hemodynamically stable, with a stable hematocrit and resolution
of symptoms.
Discharge Instructions:
You were admitted to the hospital with GI bleeding likely from
small outpouchings of the large intestine (diverticulosis).
.
Your metoprolol was increased to 25 mg by mouth three times
daily. No other changes were made to your medications. Please
continue taking your medicines at the usual dosages.
.
Please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 1579**] to make an appointment in the next 7 days.
.
Please return to the Emergency Room if you experience fever,
chills, sweats, lightheadedness, dizziness, visual changes,
chest pain, palpitations, shortness of breath, abdominal pain,
blood in the stool, or dark stools.
Followup Instructions:
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2179-2-8**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2179-6-3**] 10:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2178-10-5**]
|
[
"V58.61",
"276.52",
"457.1",
"272.0",
"682.6",
"427.31",
"715.36",
"287.5",
"278.01",
"327.23",
"V45.82",
"427.1",
"414.01",
"729.89",
"V45.86",
"562.12",
"401.9",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.05",
"38.93",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7495, 7501
|
3696, 6626
|
320, 338
|
7975, 8054
|
2461, 3673
|
8800, 9256
|
1936, 1966
|
6982, 7472
|
7522, 7522
|
6652, 6959
|
8078, 8777
|
1981, 2442
|
7618, 7954
|
275, 282
|
366, 1390
|
7541, 7597
|
1412, 1747
|
1763, 1920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,017
| 133,476
|
7894
|
Discharge summary
|
report
|
Admission Date: [**2108-1-4**] Discharge Date: [**2108-1-27**]
Date of Birth: [**2034-4-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
Wt loss and abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic lymph node biopsy of the mesentery and
retroperitoneum
bone marrow biopsy and aspirate ([**2108-1-12**] and [**2108-1-27**])
thoracocentesis ([**2108-1-10**])
History of Present Illness:
This is a 73 year-old Vietnamese man with the history below
presents with wt. loss, loss of appetite and dull aching
abdominal pain for a month, associated with chills, sweats. The
pain is constant, alleviated by eating. Does not burn or
radiate. Denies vomiting, hematemis, diarrhea, BRBPR or melena.
He also has had a cough for 9 days.
Past Medical History:
Past Medical History:
back pain, gunshot wound in the left clavicle,
hepatitis B, headaches, weight loss, cataracts, advanced
glaucoma, GERD
Mult. adenomas on colonoscopy done in [**2105**].
Social History:
Emigrated from [**Country 3992**] in [**2079**]. States that he has never been
tested for TB. Smoked 2 PPD for the past 59 years (quit two
weeks ago). No ETOH or other drugs. Parents were both murdered
in the war (hung). Pt. became inconsolable, crying, on raising
this topic. He was shot multiple times (leg, shoulder).
Family History:
Parents murdered (hung) during [**Country **] war by the Viet Cong.
His wife and children live in [**Country 3992**] now, and are healthy.
Physical Exam:
T Max (past 24 hours): Temp: 99.1 BP: 99/73 HR:83 RR:18
Oxygen Saturation: 98 (on room air)
.
General Appearance: pleasant, comfortable, NAD, thin, wasted
.
Ophthalmologic/Eyes: : PERLLA, EOMI, no conjuctival injection,
anicteric
.
Otolaryngologic (ENT): no sinus tenderness, moist mucous
membranes, oropharynx without exudate or lesions, no
supraclavicular or cervical lymphadenopathy, no thyromegaly or
thyroid nodules
.
Cardiovascular: Regular rate and rhythm, normal S1 and S2, no
murmurs, rubs, or gallops appreciated.
.
Respiratory: CTA b/l with good air movement throughout
.
Gastrointestinal/abdomen: distended, soft. Palpable mass, +b/s,
diffusely tender to palpation. No hepatomegaly.
.
Genitourinary: no catheter in place
.
Musculoskeletal: no cyanosis, clubbing or edema
.
Integumentary: skin warm, no rashes, no jaundice
.
Neurological: Alert. Oriented to self, time, place, situation.
CN II-XII intact. 5/5 strength throughout. No sensory deficits
to light touch appreciated. No pass-pointing on finger to nose.
2+DTR's-patellar and biceps. No asterixis, no pronator drift,
fluent speech. Gait and station: intact
.
Psychiatric:pleasant, appropriate affect; very tearful, crying
when discussing death of parents.
.
Heme/Lymph: no cervical or supraclavicular lymphadenopathy; no
axillary or groin adenopathy.
Pertinent Results:
CT abdomen and pelvis:[**1-4**]
1. No evidence of retroperitoneal bleed.
2. Confluent soft tissue throughout the abdomen is most
suggestive of lymphoma, appears unchanged since [**2107-12-29**].
3. Stable small bilateral pleural effusions.
4. Trace amount of pelvic free fluid.
CT chest:[**1-5**]
IMPRESSION:
1. Moderate bilateral pleural effusions with atelectasis of the
adjacent lung parenchyma. The pleural effusions are increased
from [**2108-1-5**] and new from [**2107-12-29**].
2. Rounded hypodense lesion within the atelectatic left lung
base, which may represent a pulmonary nodule. Recommend
follow-up CT after resolution of the pleural effusion for better
assessment.
3. Patchy opacities in the posterior upper lobes bilaterally.
This may be secondary to dependent atelectasis or an aspiration
event.
4. Enlarged left supraclavicular lymph node and bulky confluent
nodal masses in the abdomen; the latter have increased in size
compared to [**2107-12-29**].
.
retroperitoneal lymph node:
Monomorphous population of large atypical lymphoid cells,
necrosis and blood.
.
mesenteric lymph node:
Sections show a diffuse infiltrate of predominantly medium-sized
cells with amphophilic cytoplasm, round nuclear contours, fine
chromatin, and one to several nucleoli. Numerous apoptotic
bodies and mitotic figures are present. This increased
proliferation is admixed with histiocytes that imbibe apoptotic
cells (tingible-body macrophages), imparting a "starry-[**Hospital Ward Name **]"
appearance. By immunohistochemistry, the lymphoid infiltrate is
diffusely immunoreactive for B-cell markers CD20 and PAX5, with
co-expression of CD10 (major subset), bcl-2, and bcl-6. They
are negative for TdT and bcl-1. MIB-1 shows a proliferation
index of more than 95%. CD3 highlights scattered T-lymphocytes.
CD138 stains scattered plasma cells. In situ hybridization
study for [**Last Name (un) **], performed at [**Hospital6 1708**] ([**Hospital1 112**]),
is negative. FISH studies performed on unstained tough preps of
the biopsy to look for c-myc rearrangement shows a normal
hybridization pattern (see separate cytogenetics report).
The differential diagnosis based on H&E morphology includes a
high grade diffuse B-cell lymphoma, Burkitt or atypical Burkitt
lymphoma, blastoid mantle cell lymphoma and lymphoblastic
lymphoma. Negative BCL1 and TdT immunostains do not favor a
mantle cell lymphoma or lymphoblastic lymphoma, respectively.
The positive BCL2 immunostains and negative myc translocation
are against a Burkitt lymphoma, despite certain morphologic
features. Overall, the features are that of a high grade
diffuse B-cell lymphoma.
.
pleural fluid:
POSITIVE FOR MALIGNANT CELLS
consistent with lymphoma (see note).
Note:
The diagnosis is based primarily on flow cytometry
(S07-[**Numeric Identifier 28406**]). The smear shows large cells with round nuclei,
course chromatin and scant cytoplasm and admixed small
lymphcytes.
.
MRI head w/o contrast
Limited exam without evidence of lymphoma or acute intracranial
process.
.
Bone Marrow Biopsy
1. Hypercellular erythroid dominant bone marrow with erythroid
and megakaryocytic dysplasia
2. Increased hemophagocytic histiocytes
3. Definitive diagnostic/morphologic evidence of lymphoma is
not seen.
.
CXR [**1-4**]
IMPRESSION: Patchy nodular infiltrate at the left lung base, new
since [**3-17**], which may be pneumonic.
.
CTA chest [**1-16**]
1. No pulmonary embolus.
2. Rounded opacity in the left lower lung is concerning for
pneumonia.
3. Moderate bilateral pleural effusions. The left pleural
effusion has slightly decreased since [**2108-1-11**].
.
CXR [**1-25**]
Since the previous examination, there is significant improved
aeration of both lungs with almost complete resolution of the
bibasilar dependent atelectasis and the pleural effusion. Note
that the lungs are emphysematous.
Brief Hospital Course:
1) Abdominal mass:
He initially presented with LUQ abdominal pain and associated
weight loss,
fevers, night sweats, dyspnea, nodular gastric/duodenal folds,
splenic [**Doctor First Name **], pararenal [**Doctor First Name **], para-[**First Name9 (NamePattern2) 28407**] [**Doctor First Name **], normocytic anemia,
thrombocytopenia and hypoalbuminemia. His mass was
radiographically concerning for lymphoma v. primary intestinal
(gastric) adenocarcinoma. The constellation with weight loss
was particularly concerning. He had a laparoscopic lymph node
biopsy of an abdominal node as well as a retroperitoneal node
(full results in results section) that showed high grade B cell
lymphoma. A bone marrow biopsy showed histiocytosis but no
lymphoma. He also had bilateral pleural effusions, and
underwent a thoracocentesis which showed malignant effusion. He
started [**Hospital1 **] chemotherapy and tumor lysis labs were followed
closely as there was initial concern for Burkitts which would
create a high liklihood of tumor lysis. His tumor lysis labs
were negative throughout and he received aggressive IV
hydration. The final read on his pathology was high grade B
cell lymphoma. He received filgrastim 24 hours after his last
chemo dose as per protocol. Over the next several days his
neutrophil count decreased. On [**1-25**] he was no longer
neutropenic. He will be followed by Dr. [**Last Name (STitle) **] and will be
re-admitted to the hospital on [**2-2**] for cycle 2 of [**Hospital1 **]. An
outpatient bone marrow biopsy and aspirate is planned to
reevaluate his bone marrow.
.
2) Pulmonary
On admission he had a cough and an infiltrate on CXR. He was
started on cefepime.
After beginning to receive [**Hospital1 **] and aggressive hydration he had
an acute oxygen desaturation and temporary hypotension and was
transferred to the MICU. He did well on a facemask and returned
to the BMT service the following day. He was transferred to the
MICU initially on [**1-13**] for episode of hypoxia with O2
saturation of 88-90% on 2LNC. ABG with pH7.48 CO2 41 and paO2
71 on 5LNC. He had theraputic left sided thoracentesis with
removal of 850ml pleural fluid. His O2 saturation improved to
high 90's on 4L NC and he was transferred back to BMT on [**1-14**].
He had a CTA which was negative for pulmonary embolus. He
bounced back to the ICU on [**1-15**] for a transient episode of
hypoxia thought likely due to combination of bilateral malignant
pleural effusions and possible new LLL pneumonia. He was
treated with vancomycin cefipime and levofloxacin. He remained
afebrile and hemodynamically stable. In addition, he was gently
diureses with lasix 10 IV as his volume status was net positive
likely due to hydration for tumor lysis syndrome. He was
continued on [**Hospital1 **] per BMT recommendations and prophylaxis for
tumor lysis syndrome. Vancomycin and levofloxacin were stopped
on day 3, as suspicion for pneumonia low. He was transfused 1
unit PRBC on [**1-15**] for HCT <25, thought most likely [**2-18**] marrow
supression. He was guiaic negative throught his ICU stay. His
O2 saturation was stable and in the high nineties on 6L when he
was transferred. His oxygen saturation remained in the high
nineties while on the BMT service and gradually he returned to
room air and was satting in the high nineties. His cough also
subsided. His vancomycin was discontinued but the cefepime was
continued for a full 2 week course. He remained afebrile. A
chest X ray done [**1-25**] showed almost complete resolution of his
effusions, no infiltrate and some emphysema.
3.)ID
After completing [**Hospital1 **], infectious disease was called to
evaluate him for prophylaxis while neutropenic as he is from
rural [**Country 3992**]. As he had fever, nightsweats and an infiltrate
on admission it was felt that he needed to be ruled out for
tuberculosis. He was placed on precautions and had three
consecutive negative AFB smears. Serologies for strongyloides,
histoplasmosis, blastomycosis, aspergillus, HSV 1&2 were sent
and are pending. HCV was negative. He has a history of Hep B
infection and was placed on lamivudine to prevent recrudescence.
He will likely remain on this throughout his chemo cycles.
Medications on Admission:
Tylenol # 3
[**Name (NI) 28408**]
Aspirin
(pt. has others on list, including methadone, but states he only
takes these three).
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*2*
8. Ensure Liquid Sig: One (1) bottle PO twice a day.
Disp:*30 bottles* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
high grade B cell lymphoma
malignant pleural effusions-bilateral
history of hepatitis B infection
Glaucoma OD
Hospitalized for his back injury.
PTSD
Discharge Condition:
stable, afebrile, good po intake, ANC 7230, ambulatory
Discharge Instructions:
You were admitted with abdominal pain. On your chest X ray
there was evidence of pneumonia that was treated. You had an
abdominal CT that showed soft tissue, and you had a biopsy of
some of your lymph nodes that showed B cell lymphoma (cancer).
Your bone marrow at that time was abnormal but did not show
lymphoma. You also had collections of fluid in your lungs that
was due to the lymphoma in your abdomen. You had some of the
fluid removed. You received chemotherapy ([**Hospital1 **]) but had low
oxygen from fluid accumulation in your lungs. You were in the
intensive care unit but then your oxygen improved so you were
moved to the bone marrow transplant floor. Your oxygen
decreased again and you were briefly in the ICU again. After
decreasing your fluid intake you improved and were on the bone
marrow transplant floor where you were evaluated by infectious
disease specialists. You were evaluated for tuberculosis
infection for three days and were found not to have
tuberculosis. Your white blood cell count dropped because of
the chemotherapy and you were receiving a medication that helps
the white blood cells recover. Your white blood cell count is
now close to normal.
You should take levofloxacin 500mg by mouth daily, as well as
lamivudine 100mg by mouth daily, and bactrim by mouth daily
until you see your doctor. You will likely have to stay on the
lamivudine throughout your chemotherapy courses.
You should follow up as outlined below.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2108-1-31**] 12:30
Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2108-1-31**] 12:30
Completed by:[**2108-1-31**]
|
[
"309.81",
"202.80",
"458.29",
"285.9",
"486",
"287.5",
"263.0",
"799.02",
"783.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"40.11",
"38.93",
"99.25",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
12276, 12282
|
6864, 11122
|
341, 515
|
12475, 12532
|
2978, 6841
|
14050, 14406
|
1463, 1604
|
11300, 12253
|
12303, 12454
|
11148, 11277
|
12556, 14027
|
1619, 2959
|
274, 303
|
543, 887
|
931, 1102
|
1118, 1447
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,246
| 124,035
|
2754
|
Discharge summary
|
report
|
Admission Date: [**2128-9-4**] Discharge Date: [**2128-9-6**]
Date of Birth: [**2067-10-24**] Sex: F
Service:
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
white female with a history of congestive heart failure and
diabetes who comes in with hypotension, renal failure, and
hypercalcemia.
The patient was previously admitted in [**2128-7-19**] with
a similar complaint and treatment for hypovolemia and found
to have Klebsiella, Staphylococcus aureus, [**Female First Name (un) 564**]
bacteremia. Later found to have an elevated INR with
guaiac-positive stool. Her hematocrit had fallen, and the
patient was given one unit of packed red blood cells. The
patient went to the Emergency Department but refused to stay.
The patient came to the Emergency Department today because of
feeling "lightheaded." Notes having diarrhea today. Not
watery. Reports being constipated in the past five days.
The patient denies melena, hematochezia, nausea, or vomiting.
She reports initially feeling lightheaded when standing up
which improved with time. Also started having an increase in
bowel movements which were black in color. The patient
denies paroxysmal nocturnal dyspnea or orthopnea. She has
increased swelling in the legs. No chest pain or shortness
of breath. Continues dopamine infusion at home. She denies
fevers, chills, cough, abdominal pain, or dysuria.
Over the past week the patient had black stool one week ago
and then took Imodium which resolved her symptoms. The
patient has been taking potassium supplements as well. In
the Emergency Department, the patient's potassium was found
to be 7.4. She was given calcium, insulin, glucose, and
Kayexalate times two. She was continued on vancomycin, and
levofloxacin, and Flagyl bolused with one liter of normal
saline. Her initial blood pressure was 52/30s. Nasogastric
lavage was negative. The patient was admitted to the
Coronary Care Unit team for further workup.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft in [**2120**] and myocardial infarction in [**2120**].
Coronary artery bypass graft plus mitral valve repair in
[**2120**], internal mammary artery with coronary artery disease,
saphenous vein graft to obtuse marginal, saphenous vein graft
to right posterior descending artery.
2. Chronic congestive heart failure (on home dopamine) and
biventricular pacers. Ejection fraction around 20%. Stress
MIBI revealed severe inferior and lateral wall defects,
fixed.
3. Diabetes mellitus.
4. History of gastrointestinal bleed and arteriovenous
malformation, status post cautery in [**2128-2-17**]. Her
baseline hematocrit is around 30%.
5. Chronic renal insufficiency (with a baseline creatinine
of 1.3 to 1.4).
6. Peripheral vascular disease: known total occlusion
abdominal aorta. 7. SP mCoagulase-negative line infection.
8. Mitral valve replacement: mechanical prosthetic valve
requiring coumadin.
9. DDD pacer, with atrial tachycardia recent revision.
MEDICATIONS ON ADMISSION: IV dopamine 8 mcg per kg per min,
enalapril, spironolactone, carvedilol, lasix, bumex
intermittant. Antidepressants as noted on recent dc summary.
Coumadin, adjusted per INR. Aspirin. Statin.
ALLERGIES: LOPRAZOLAM, SULFA, CODEINE, and CECLOR, and
CEPHALEXIN.
SOCIAL HISTORY: The patient lives with her husband.
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination revealed the patient's heart rate was 80, she was
afebrile, her blood pressure was 88/50, her respiratory rate
was 18, and her oxygen saturation was 100% on 2 liters nasal
cannula. Head, eyes, ears, nose, and throat examination
revealed sclerae were anicteric. Pupils were equal, round,
and reactive to light and accommodation. Extraocular
movements were intact. The mucous membranes were moist. The
neck was supple. No lymphadenopathy. Jugular venous
pulsation at 12 cm. No bruits auscultated. Pulmonary
examination revealed no wheezes or crackles anteriorly.
Cardiovascular examination revealed normal first heart sounds
and second heart sounds with a systolic click. The abdomen
was soft, nontender, and nondistended. No
hepatosplenomegaly. Positive bowel sounds. Extremity
examination revealed 1+ edema in the lower extremities with
diffuse chronic mottled appearance in the lower extremities.
Neurologic examination revealed the patient was alert and
oriented times three. Cranial nerves II through XII were
grossly intact. No focal motor deficits.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory
values on admission revealed the patient's white blood cell
count was 8.7, the patient's hematocrit was 27.5, and her
platelets were 194, and her mean cell volume was 88. INR was
2.2 and partial thromboplastin time was 32.6. Sodium was
127, potassium was 7.4, blood urea nitrogen was 75, and
creatinine was 2.7. Alkaline phosphatase was 79, total
bilirubin was 0.3, ALT was 13, AST was 22, amylase was 67,
and her lipase was 39. Albumin was 3.9.
PERTINENT RADIOLOGY/IMAGING: Prior echocardiogram in
[**2128-7-19**] revealed moderate tricuspid regurgitation,
ejection fraction of 20%, right ventricular function
decreased, right ventricle mildly dilated, severe left
ventricular global hypokinesis, right atrial dilatation, LA.
Mechanical mitral valve without overt masses.
A chest x-ray revealed cardiomegaly and pacemaker. No
evidence of infiltrates or evidence of volume overload.
Electrocardiogram revealed a rate of 60s, paced, with a
atypical bundle-branch block pattern.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted for lightheadedness, increase in bowel
movements, with questionable melena, and hyperkalemia.
1. CARDIOVASCULAR ISSUES: Ischemia: No evidence of
ischemia. Has a history of a fixed perfusion deficits. The
patient was continued with statin. Aspirin was initially
held in light of gastrointestinal bleed. The patient was
continued with ACE inhibitor. Chronic IV dopamine was
continued.
The patient was continued on carvedilol and diuresed with
appropriate electrolyte management. Followed potassium and
creatinine function.
The patient was initially increased on dopamine drip to 10
mcg/kg per minute with an eventual wean to home baseline of 8
mcg/kg per minute with appropriate maintenance of her blood
pressure; per her baseline. In addition, the patient was
transfused one unit of packed red blood cells for hematocrit
elevation to greater than 30.
2. HEMATOLOGIC ISSUES: In terms of the patient's fall in
hematocrit, nasogastric lavage was negative. Given the
patient's prior history of arteriovenous malformation, an
esophagogastroduodenoscopy was performed. This revealed
pinpoint bleeding in the second part of the duodenum which
was cauterized with appropriate post procedural hemostasis.
The patient's hematocrit remained stable status post
procedure at 29 to 30.
The patient was discharged with guaiac cards to follow with
three serial stool samples to be brought to her next
follow-up visit. Given the need for anticoagulation,
Coumadin was restarted with a modified goal INR of 2 to 3. In
addition, the risks of an aspirin was less significant than
her need for her significant cardiac history and was
continued on aspirin 81 mg by mouth once per day along with a
proton pump inhibitor. The patient was to be monitored in
two days for appropriate INR therapy. Given the patient's
recent antibiotic therapy, this was felt to have contributed
to her elevated INR and will need to be monitored closely as
she is currently off her fluoroquinolones.
3. FLUIDS/ELECTROLYTES/NUTRITION/RENAL ISSUES: The
patient's increased creatinine was likely acute prerenal
azotemia from acute GI bleed in setting of chronic poor
perfusion. The patient's
weight was monitored and bolused appropriately. Blood and
urine electrolytes were monitored maintaining even fluid
status. Increased dopamine for proper renal perfusion.
Spironolactone was held acutely in light of hyperkalemia. As
well, potassium supplements were held. The patient's
creatinine
subsequently improved with good diuresis to 2.7 to 2.1. At
the time of discharge, the patient's creatinine was 1.1; at
her baseline. At the time of discharge, the patient's Lasix
was to be continued at 80 mg by mouth twice per day as
well as 2 gram sodium diet with daily
appropriate weight and volume [**Year (4 digits) 7941**].
4. INFECTIOUS DISEASE ISSUES: Given the patient's history
of bacteremic Klebsiella, and methicillin-resistant
Staphylococcus aureus, and fungal infection peripheral blood
cultures were drawn and were no growth to date. Cultures
drawn at an outside hospital (at the [**Last Name (un) 4068**]) on [**2128-9-2**] were without growth to date at the time of this
dictation. Appropriate followup would be recommended as
final results were still pending and the patient is currently
off antibiotics. The patient remained afebrile throughout
with a negative chest x-ray on line status was without
evidence of infiltration or infection.
DISCHARGE STATUS: The patient was discharged on [**2128-9-6**] with [**Hospital6 407**] home care for laboratory
and dopamine infusion.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Atorvastatin 10 mg by mouth once per day.
2. Carvedilol 6.25 mg by mouth twice per day
3. Amiodarone 200 mg by mouth once per day.
4. Epogen injections one times per week.
5. Dopamine at 8 mcg/kg per minute.
6. Sertraline 100 mg by mouth twice per day.
7. Trazodone 50 mg by mouth at hour of sleep as needed.
8. Pantoprazole 40 mg by mouth once per day.
9. Furosemide 80 mg by mouth twice per day.
10. Enalapril 5 mg by mouth twice per day.
11. Spironolactone 25 mg by mouth once per day.
12. Lorazepam 1 mg by mouth at hour of sleep as needed.
13. [**Doctor First Name **] 60 mg by mouth twice per day.
14. Colace 100 mg by mouth twice per day.
15. Warfarin 5-mg tablets 0.5 tablets at 2.5 mg by mouth
once per day.
16. Aspirin 81 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was given a sack of guaiac cards placed in
ziploc bags times three to bring in to next appointment.
2. The patient was to have blood laboratory chemistries,
Chemistry-7, coagulations, and complete blood count drawn on
[**2128-9-9**] for followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2128-9-16**]. Formal continue followup with Advanced Heart
Failure Program was arranged in detail with patient prior to
dc. 3. The patient was instructed to call if she developed
shortness of breath, weight gain, lower extremity edema,
fevers, chills, or nausea.
4. The patient was encouraged to resume a congestive heart
failure diet as well as to increase exercise as tolerated.
5. The patient was instructed to call if she noticed any
darkening in the color of her stool or any bright red blood
per rectum.
6. The patient was again advised to avoid any use of
cigarettes.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Dictator Info 13592**]
MEDQUIST36
D: [**2128-9-6**] 13:55
T: [**2128-9-9**] 07:45
JOB#: [**Job Number 13593**]
|
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icd9cm
|
[
[
[]
]
] |
[
"44.43",
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] |
icd9pcs
|
[
[
[]
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9319, 10105
|
3080, 3342
|
10138, 11329
|
5631, 9241
|
9256, 9292
|
144, 158
|
187, 2001
|
2023, 3054
|
3359, 5596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,543
| 173,583
|
44755+58757
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-1-8**] Discharge Date: [**2142-2-10**]
Date of Birth: [**2092-4-6**] Sex: M
Service: NEUROLOGY
Allergies:
Iodine; Iodine Containing / Bactrim
Attending:[**First Name3 (LF) 13252**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
ACDF
History of Present Illness:
49 year-old man with PMH DM type I, HTN, ESRD on HD for 4
years now s/p kidney transplantation [**9-/2141**] complicated by
delayed graft function who p/w pain in both hands, radicular
type
pain in his right leg, diffuse weakness, mostly proximal; R>L.
Patient had a renal transplant in [**9-/2141**] complicated by delayed
graft function. He also developed 3 weeks after transplant pain
in both his hands, he described as a "pricky" sensation in all
fingers and palm of his hands. He denied numbness. At that time
he had an elevated level of Prograf; ([**12-21**]; 47.8); reduction
of
medication dosing correlated with improvement in his hand pain.
He reports that he has had for several years decreased sensation
in both feet.
He has lost a significant amount of weight since his transplant
(around 30 pounds); he feels weaker throughout. He has had more
difficulty to walk; he has had more frequent falls (last one
today, he thought he tripped over on the floor). He also has
complaints of worsening pain irradiating through the right leg,
posteriorly, down to R foot. He also thinks that his hands and
arms are weaker bilaterally; he has had trouble to open the
bottles of his medications, to comb his hair along the past few
months.
He underwent an [**Month (only) 2841**] today performed by Dr. [**Last Name (STitle) 1206**] which
revealed
progression of his polyneuropathy, but also denervation in an L5
distribution and proximal myopathic changes and was referred to
ED for admission for further work-up.
Past Medical History:
1. CAD s/p [**Last Name (STitle) **] to OM1 in [**9-2**] and [**Month/Day (1) **] to RCA in [**5-5**]
2. End-stage renal disease, on HD since [**6-3**] (MWF)
3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin,
c/b nephropathy, neuropathy, and retinopathy status post
multiple laser surgeries. Right upper extremity fistula. Chronic
ulcers on left foot.
4. Hypertension
5. Hyperlipidemia
6. Obstructive sleep apnea
7. G6PD deficiency
8. Right fifth toe amputation, [**2137-3-29**].
9. History of hepatitis B infection
10. Sexual dysfunction s/p penile prosthesis implantation
11. Kidney transplant, right iliac fossa [**2141-10-14**].
12. Celiac disease
Social History:
The patient lives with his wife and 2 sons in [**Name (NI) 669**].
Previously worked at NSTAR as a janitor, and is currently on
diability. No tobacco or EtOH use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother has diabetes mellitus. Father is healthy
and multiple half brothers and sisters. Two children, both boys,
are healthy. Multiple aunts and uncles decreased from
complications of diabetes. No family hx of Wegener's or
[**Last Name (un) 95749**]-[**Doctor Last Name 3532**] disease.
Physical Exam:
T98.6 HR 73 BP 129/63 RR16 O2 100% RA
Gen: Awake, alert, lying in bed; looks cachetic
Skin: No rashes. Abrasions on R knee (reportedly from fall)
Heent: NCAT, no conjunctival injection, mucous membranes moist,
oropharynx clear.
Neck: Supple, no meningismus.
Extrem: no edema
Neuro:
MS - Awake, alert, interactive. Oriented to person, place, and
date. Speech is fluent, with intact registration/recall,
repetition, naming, comprehension. Could say [**Doctor Last Name 1841**] backwards.. No
left-right confusion.
Cranial Nerves ?????? PERRL 3-->2, EOM smooth and full, no diplopia;
no nystagmus; Visual field mild/mod restricted in all
directions,
intact facial sensation, face symmetric with full strength of
facial muscles, hearing intact to finger rub bilaterally, palate
elevation is symmetric, and tongue protrusion is symmetric and
full movement. Trazpezius full bilat.
Motor:
diffuse atrophy; R pronator drift
Delt [**Hospital1 **] Tri WrEx FEx FFlx IO [**Location (un) **] / IP Quad Ham Gastr TA [**Last Name (un) 938**]
R 4- 5 4- 5- 4+ 5- 5- 5- 4- 5 5- 5- 5- 5-
L 4 5 4+ 5- 4+ 5- 5- 5- 4+ 5 5- 5- 5- 5-
Reflexes -
Biceps Triceps Brachioradialis Patellar Ankle
R 3+ 3+ 3+ trace 0
L 3- 3+ 3+ trace 0
Plantar responses mute
Sensation - Decreased sensation to pinprick and JPS distally in
hands (fingers), cold sensation intact in UEs but slightly less
at distal hands. Decreased sensation to cold, pinprick and
vibration below the knees in LEs, JPS absent at the toes.
Coordination - No dysmetria and smooth finger to nose. RAMs
normal and symmetric.
Gait - Wide based; very unsteady, falls to both sides
Pertinent Results:
Admission Labs:
140 112 31 185 AGap=13
-----------<
4.7 20 1.8
WBC5.0 Hv 11.6 plat235 Ht36.9
N:81.4 L:13.9 M:3.0 E:0.9 Bas:0.8
Imaging:
MRI
CERVICAL SPINE: Bone marrow signal is abnormally hypointense on
all
sequences, similar to that seen on the prior examination and may
relate to the
patient's underlying hemosiderosis. There is 2 mm of
retrolisthesis of C3 on
4. There is extensive [**Last Name (un) 13425**]-type 2 and 3 endplate changes and to
a lesser
extent [**Last Name (un) 13425**] type 1 endplate change centered at C3-C4. No
additional marrow
signal abnormalities are appreciated.
At C2-3, there is no canal or foraminal narrowing.
At C3-4, there is a progressive spondylosis with a central disc
herniation
resulting in severe canal narrowing with cord deformity and
abnormally
increased T2 signal. There is severe bilateral foraminal
narrowing.
At C4-5, there is a spondylotic ridge with a broad central disc
herniation
resulting in moderate canal narrowing as well as mild bilateral
foraminal
narrowing. There is flattening of the ventral cord surface
without abnormal
cord signal.
At C5-6, there is a broad spondylotic ridge with a central disc
protrusion
resulting in mild canal narrowing with slight flattening of the
ventral cord
surface. There is mild bilateral foraminal narrowing, left
greater than
right.
At C6-7, there is mild spondylosis and facet arthropathy without
significant
canal or foraminal narrowing.
At C7-T1, there is no significant canal or foraminal narrowing.
IMPRESSION:
1. Severe canal and bilateral foraminal narrowing at C3-4 with
cord deformity
and abnormally increased T2 signal.
2. Moderate canal narrowing at C4-5.
3. Additional degenerative changes as detailed.
LUMBAR SPINE: Bone marrow signal is abnormally hypointense on
all sequences,
similar to that seen on the prior examination and may relate to
the patient's
underlying hemosiderosis. Sagittal alignment is satisfactory.
The conus
terminates at T12-L1. Again noted is extensive multilevel [**Last Name (un) 13425**]
type 2
endplate change with [**Last Name (un) 13425**] type 1 endplate change at L4-5 and to
a lesser
extent L5-S1. There is a rudimentary disc space at S1-2.
At L3-4, there is mild disc desiccation without significant
canal or foraminal
narrowing.
At L4-5, again noted is a disc bulge with central annular tear
and a small
inferiorly migrated disc fragment creating moderate bilateral
subarticular
zone narrowing. When combined with the facet arthropathy and
endplate spur,
there is severe right foraminal narrowing and mild left
foraminal narrowing.
At L5-S1, there is a disc bulge and facet arthropathy with a
central/left
paracentral inferiorly migrated fragment resulting in severe
narrowing of the
left subarticular zone and lateral recess with potential for
compression of
the traversing left S1 root. Additionally, there is severe
narrowing of the
left neural foramen and moderate right foraminal narrowing.
There is a right pelvic kidney.
IMPRESSION:
1. Diffusely abnormal hypointense bone marrow signal is
unchanged from the
prior study and likely relates to hemosiderosis. There are
superimposed [**Last Name (un) 13425**]
type 1 and 2 endplate changes.
2. Moderate bilateral subarticular zone narrowing at L4-5 with
severe right
foraminal narrowing, similar to that seen on the prior study.
3. Severe narrowing of the left subarticular zone and lateral
recess as well
as the left neural foramen at L5-S1 with potential for
compression of the left
L5 and/or S1 roots. The appearance is similar to that seen on
the prior
study.
Bone Scan:
INTERPRETATION: Whole body images of the skeleton were obtained
in anterior and
posterior projections.
There is focused increased radio-isotope uptake probably in the
6th rib in the
rib-end. No other increased radio-isotope uptake is seen, in
particular, there
is no abnormal uptake in C3.
The above described findings are consistent with non-specific
likely
inflammatory changes or post traumatic changes of the right 6th
rib.
The renal transplant is visualized in the right iliac fossa, and
urinary bladder
is also visualized, due to the normal excretion of the
radio-isotope.
Discharge Labs:
139 | 108 | 26
--------------< 103
4.8 | 26 | 1.2
Ca: 9.6 Mg: 1.9 PO4: 2.3
9.5
2.7 >-----< 159
32.5
Tacro level: 4.1
Brief Hospital Course:
49 year old man with PMH DM, HTN, ESRD on HD for 4 years now s/p
kidney transplantation [**9-/2141**] complicated by delayed graft
function who p/w BL hand pain, diffuse weakness, mostly proximal
R>L.
Mr. [**Known lastname 449**] had an MRI which showed severe stenosis with cord
deformity at C3/C4. He had a bone scan which showed no signs of
metastasis or infection. On [**1-11**] he underwent an ACDF. Per
Orthopedics, he will need to undergo a posterior fusion in the
future, but it is not required during this admission.
Post-operatively he was noted to have an extremely swollen left
arm. This was thought to be due to an infiltrated IV.
Additional IV access was unable to be obtained, so a PICC was
placed. His arm was elevated and warm compresses were applied,
with significant improvement. PICC should be discontinued as
soon as IV access is no longer needed.
Post-operatively the patient complained occasionally of the
sensation of food sticking in his throat. A swallowing
evaluation showed normal swallowing ability, but given
post-operative pain it was recommended that his diet consist of
ground solids and thin liquids. This should be reassessed as
his post-operative pain improves.
Overnight on [**1-16**] Mr. [**Known lastname 449**] did have a temperature of 101.3. He
had urine and blood cultures that have been negative to date,
and a chest X-ray with no signs of infection. His wound was
assessed by ortho, and showed no signs of infection. It was
thought this may be due to post-operative atelectasis, and he
has been afebrile since.
For his DM, the patient was followed by [**Last Name (un) **] during his
hospitalization, and his current regimen consists of 46U NPH in
am and 34U NPH [**Last Name (un) **]. He also has a Lispro sliding scale detailed
in the discharge paperwork.
The renal transplant team also followed Mr. [**Known lastname 449**] while he was
hospitalized. His tacrolimus levels were followed. His level
on admission was 11, so his dose was initially decreased to
2.5mg [**Hospital1 **], however his level decreased to 4, so he was increased
back to his admission dose of 3mg [**Hospital1 **], with the level at
discharge being 4.1. Please check tacrolimus level in 1 week,
with a goal of [**8-7**]. He was also given a dose of pentamidine
for PCP [**Name Initial (PRE) 1102**]. Valgancyclovir was discontinued on
Given his report of significant weight loss, calorie counts were
obtained, which showed initial poor PO intake, which was
primarily attributed to post-operative pain, and improved
Exam at discharge was notable for mild proximal weakness in his
upper extremities, and significant bilateral foot drop ([**3-2**]
bilateral at TA). He has a significant peripheral neuropathy,
with decreased proprioception to the level of his knees.
Medications on Admission:
-albuterol
-ergocalciferol 50,000 Q weekly
-insulin lispro 10Uam; 12U pm
-Insulin NPH SS
-isosorbide mononitrate 60mg daily
-lipitor 80mg daily
-lyrica 50mg [**Hospital1 **]
-loperamide 2mg PRN
-metoprolol succinate 200mg [**Hospital1 **]
-CellCept 500mg QID
-NitroQuick 0.4mg SL PRN
-pentamidine 300mf [**Male First Name (un) **]
-ranitidine 150mg daily
-tacrolimus 3mg [**Hospital1 **]
-trazodone 50mg HS
-valgancyclovir 900 mg Qday
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a
day).
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
12. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for meals.
13. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
14. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
15. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
17. Humalog 100 unit/mL Solution Sig: Sliding scale
Subcutaneous AC and HS: 71-150 6U
151-200 8U
201-250 10U
251-300 12U
301-350 14U
351-400 16U.
18. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Forty
Six (46) units Subcutaneous Qam.
19. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
Four (34) Units Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center
Discharge Diagnosis:
Primary: Severe C3 stenosis with cord compression
Secondary: Diabetes. ESRD s/p kidney transplant. Celiac disease.
Peripheral neuropathy.
Discharge Condition:
Mild proximal upper extremity weakness (5- in triceps
bilaterally, 4+ in L deltoid). Right IP 4+, left full strength.
Bilateral foot drop ([**3-2**] in both TA). Significant decrease in
proprioception to the knees bilaterally.
Discharge Instructions:
You were admitted with increasing weakness and loss of stool.
This was found to be secondary to severe cervical stenosis with
compression of the spinal cord, for which you underwent surgery.
Medication changes:
Pregabalin increased to 75mg [**Hospital1 **]
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
If you notice any of the concerning symptoms listed below,
please call your doctor or come to the emergency department for
further evaluation.
Followup Instructions:
Neurology: Dr. [**Last Name (STitle) 1206**] on [**2142-3-2**]. Please call [**Telephone/Fax (1) 2846**]
with questions.
Ortho: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] [**Telephone/Fax (1) 1228**] on [**2-9**] at 7:40 on
the [**Location (un) **] of the [**Hospital Ward Name 23**] building
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**] on [**1-25**] 9:40am
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 13255**]
Name: [**Known lastname **],[**Known firstname **] J. Unit No: [**Numeric Identifier 15202**]
Admission Date: [**2142-1-8**] Discharge Date: [**2142-2-10**]
Date of Birth: [**2092-4-6**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Bactrim
Attending:[**First Name3 (LF) 3999**]
Addendum:
After completion of the dischage summary, patient developed
fevers and so was transferred to the medicine service. The
following discharge summary represents the hospital course while
on the medical servcie and transplant surgery service from [**1-17**]
to [**2142-2-10**].
Chief Complaint:
Transfer to Medicine for persisten post-operative fevers
Major Surgical or Invasive Procedure:
[**2142-1-11**]: Anterior cervical diskectomy and fusion C3-C4
[**2142-1-30**]: Lap cholecystectomy
[**2142-2-8**]: EGD, Colonoscopy
History of Present Illness:
Mr. [**Known firstname **] is a 49 year old male with type 1 diabetes, ESRD s/p
Xplant in [**10-6**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrome (anti-TTG active in lung
tissue leading to hemoptysis when the patient eats glutin
products), hypertension, and G6PD who was initially admitted to
neurology for LE weakness, foot drop, and hand weakness. He was
found to have cervical spinal stenosis and underwent
decompression by ortho on [**1-11**]. He is being transferred from
neurology for persistent fevers post up with temp on [**1-15**] to
102.8 and now Tm 103.1and difficult to control hypertension. He
was found to have blood cultures positive for micrococcus and is
now on vancomycin/cefepime. Renal tranplant, ID, ortho,
neurology, and [**Last Name (un) 616**] have been following.
Currently, patient feels chilled. He endorsed a [**8-7**] headache
but denied photophobia or phonophobia. He currently patient
endorse dry cough since the surgery. He denies abdoinal pain or
nausea or vomiting. He reports diarrhea that started today. He
denies CP, SOB, palpitations or dysuria. He denies fevers prior
to admission.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
1. CAD s/p stent placement X 2
2. End stage renal disease, on HD since [**2138-5-29**]. [**Location (un) 382**] Dr. [**Name (NI) 15203**], s/p Renal tx [**2141-10-14**] c/b late graft function
renal biopsy allergic interstitial nephritis and treated with
oral prednisone therapy thought [**1-30**] Bactrim
3. Type 1 diabetes since age 20, complicated by nephropathy,
neuropathy and retinopathy.
4. Chronic foot ulcers
5. Hypertension
6. Hyperlipidemia
7. Obstructive sleep apnea
8. G6PD deficiency
9. Prior hepatitis B infection.
10. celiac disease
11[**Male First Name (un) **]-[**Location (un) **] syndrome/idiopathic pulmonary hemosiderosis
12. CHF, EF of 39% seen on stress test [**7-6**], also seen were
moderate defects in the inferolateral wall and the base of the
inferior wall, Moderate systolic dysfunction, with global
hypokinesis, more markedly in the inferolateral wall.
13- LGI bleed [**11-6**]
[**2142-1-11**] Partial corpectomy C4,Anterior cervical diskectomy
C3-C4,Anterior cervical arthrodesis C3-C4, Interbody
reconstruction with biomechanical device C3-C4, Anterior
cervical plate instrumentation C3-C4, Application of local
autograft for fusion augmentation, Open biopsy, deep bone.
[**2142-1-30**] Laparoscopic cholecystectomy.
Social History:
The patient lives with his wife and 2 sons in [**Name (NI) **].
Previously worked at NSTAR as a janitor, and is currently on
diability. No tobacco or EtOH use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother has diabetes mellitus. Father is healthy
and multiple half brothers and sisters. Two children, both boys,
are healthy. Multiple aunts and uncles decreased from
complications of diabetes. No family hx of Wegener's or
[**Last Name (un) 15204**]-[**Doctor Last Name **] disease.
Physical Exam:
Vitals - T: 101.1 Tm 103.1 BP:167/70 HR:84 RR:18 02 sat: 95% on
RA
BG 177-162-170-167
GENERAL: Pleasant, ill appearing male covered in blanket
appearing as if he may rigor
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dryMM. OP with thrush. Neck Supple
but in soft c-collar, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 SEM
best heard at LLSB, rubs or gallops. JVP=unable to assess [**1-30**]
c-collar
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. [**5-2**] in b/l upper ext, 4-/5 strength in
lower extremities. 2+ reflexes in upper ext b/l, 1+ reflexes in
lower ext, equal BL. Normal coordination. Gait assessment
deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Micro:
Blood cultures on [**1-15**] positive for MICROCOCCUS/STOMATOCOCCUS
SPECIES. All blood cultures negative on [**12-17**], [**1-19**], [**1-20**],
[**2142-1-11**]. Cervical spine bone biopsy.
[**2142-1-11**] 9:25 pm TISSUE C3-C4.
GRAM STAIN (Final [**2142-1-12**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15205**] @ 4:21A [**2142-1-12**].
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final [**2142-1-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2142-1-18**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2142-1-20**].
Respiratory Viral Culture (Final [**2142-1-23**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Respiratory Viral Antigen Screen (Final [**2142-1-21**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza
[**2142-1-20**]. CMV viral load negative.
[**2142-1-23**]. HBV viral load negative.
[**2142-1-22**]. Beta-glucan < 31.
[**2142-1-21**]. C. Diff negative.
[**2142-1-18**]. BK viral load negative.
Imaging:
CXR. [**2142-1-25**].
1. Satisfactory positioning of left PICC.
2.Left lower lobe or atelectasis pneumonia. Recommend followup
PA and lateral chest radiograph.
Echo. [**2142-1-22**].
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is moderate to severe symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened. There is minimal aortic stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened with characteristic rheumatic deformity.
There is mild valvular mitral stenosis (area 1.5-2.0cm2). No
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The pulmonary artery systolic pressure could
not be determined. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2141-10-18**],
the findings are similar (PA systolic pressure could not be
quantified on the current study).
Right LENI. [**2142-1-20**].
IMPRESSION: No right lower extremity DVT.
C-spine MRI. [**2142-1-19**].
IMPRESSION: Status post ACDF at C3-4, with postoperative
changes. The enhancement of the ventral dura as well as the
increased T2 signal intensity may be postoperative in nature,
although underlying infection cannot be entirely excluded by MRI
criteria. There is no drainable fluid collection.
CXR. [**2142-1-17**].
Cardiomediastinal contours are normal. Compared to prior studies
from [**1-8**], [**1-12**], there is a subtle increase in
interstitial markings in the lower lobes bilaterally, right
greater than left, although this could be atelectasis, pneumonia
cannot be totally excluded. Cardiac size is normal. There is no
pneumothorax or pleural effusion. Coronary calcifications are
evident.
[**2142-2-1**]:
SPECIMEN SUBMITTED: RIGHT BUCCAL MUCOSA LESION
Procedure date Tissue received Report Date Diagnosed
by
[**2142-2-1**] [**2142-2-1**] [**2142-2-6**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ssj??????
Previous biopsies: [**Numeric Identifier 15206**] gallbladder.
[**Numeric Identifier 15207**] C3-C4, epidural.
[**-8/4274**] Allograft renal biopsy.
[**Numeric Identifier 15208**] GI BIOPSIES (3 JARS)
(and more)
DIAGNOSIS:
Mucosa, right buccal (A):
Extensive ulceration with acute and chronic inflammation and
associated vascular thrombosis
[**2142-1-29**], gallbladder ultrasound:
IMPRESSION:
1. Distended edematous gallbladder with small stones and sludge.
Cholecystitis cannot be excluded.
2. Intrahepatic calcification along the portal triads consistent
with
vascular calcifications.
3. Splenomegaly.
4. No ascites identified.
[**2142-1-30**], gallbladder scan:
IMPRESSION: Findings most compatible with acute cholecystitis.
[**2142-1-30**]:
SPECIMEN SUBMITTED: gallbladder.
Procedure date Tissue received Report Date Diagnosed
by
[**2142-1-30**] [**2142-1-31**] [**2142-2-2**] DR. [**Last Name (STitle) **]. SEPEHR/vf
Previous biopsies: [**Numeric Identifier 15207**] C3-C4, epidural.
[**-8/4274**] Allograft renal biopsy.
[**Numeric Identifier 15208**] GI BIOPSIES (3 JARS)
[**-7/4256**] RIGHT FOOT 1ST METATARSAL EXOSTECTOMY.
(and more)
DIAGNOSIS:
Gallbladder, cholecystectomy (A-B):
1. Acute and chronic cholecystitis.
2. One reactive lymph node.
Brief Hospital Course:
49 year old male with type 1 diabetes, ESRD s/p transplant in
[**10-6**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrome, hypertension, and G6PD who was
initially admitted to neurology for cervical spinal stenosis
and was treated with surgical decompression. He developed
post-operative fevers due to hospital acquired pneumonia,
cervical spine osteomyelitis, and oral ulcers, and
cholecystitis.
Cholecystitis. Patient developed abdominal pain, diarrhea, and
fevers. CT abdomen revealed and enlarged and edematous
gallbladder. RUQ ultrasound could not rule out cholecystitis.
A HIDA scan was performed which showed no gallbladder filling.
He was taken to the OR on [**2142-1-30**] and was found to have a
gangrenous gallbladder. Lap cholecystectomy was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He was started on Vanco/Zosyn for therapy of
cholecystitis. Zosyn was given [**Date range (1) 15209**] then stopped. Vanco
continued.
?Cervical spine osteomyelitis. Patient presented with cervical
spinal stenosis and underwent spinal decompression. The bone
biopsy showed GPCs and his blood culture was positive for
micrococcus. In his immunocompromised state, it was felt that
micrococcus (found in blood cultures) was likely the pathogen
causing osteomyelitis. However, the pathology was re-reviewed
and was thought not likely to be consistent with osteo. He was
treated with vancomycin which was started on [**1-17**] with a planned
6 week course. Bone tissue was sent for universal PCR for
bacteria. This detected Streptococcus dysgalactiae DNA. ID
recommended Vancomycin for coverage of this organism.
Hospital acquired pneumonia. Patient developed cough
post-operatively and so was treated for hospital acquired
pneumonia with vancomycin and cefepime starting on [**1-18**]. His 7
day course was completed [**1-25**].
Mouth pain. Patient was treated for oral candidiasis with
fluconazole, but was briefly treated with micafungin. Given the
development of oral ulcers, he was started on acyclovir for
concern for oral HSV. As there was no improvement after several
days of acyclovir, he was switched to vangancyclovir. A viral
swab was performed of the oral ulcers to evaluate for HSV and
CMV. ENT was consulted and lesions were biopsied. Pathology
results demonstrated extensive ulceration with acute and chronic
inflammation and associated vascular thrombosis. Fungal and
viral cultures were negative including CMV and HSV. A serum CMV
viral load was negative.
Diarrhea-stools were sent for c.diff. These were negative for
c.diff. A colonoscopy was performed noting normal appearing
colon mucosa with no evidence of colitis. However, preparation
was poor so underlying lesions may have been missed. (biopsy
performed). An EGD was also performed noting gastritis and
duodentitis. Biopsies were obtained and he was started on
protonix [**Hospital1 **]. A gluten diet was ordered.
Malnutrition/weight loss-Nutrition recommended a feeding tube.
The patient was adament about holding off on a post pyloric
feeding tube. Kcals counts were started. Supplements were
provided.
Post-operative fever. Patient's post-operative fevers were
extensively evaluated. He tested negative for CMV, BK virus,
influenza, C. diff. An echo showed no endocarditis. His
post-operative fevers were attributed to cervical spine
osteomyelitis, hospital acquired pneumonia, and cholecystitis.
ESRD s/p transplant. Patient underwent renal transplanted in
[**10-6**]. He was continued on cellcept during his hospitalization
and his tacrolimus levels were frequently monitored and
adjusted. He developed worsening of his kidney function when he
developed cholecystitis. He was discharged on tacrolimus 5mg
[**Hospital1 **] for trough level of 7.4. Pentamidine inhalation was last
administered on [**1-11**] and [**2-9**].
Hypertension. Patient has difficult to control hypertension.
He was continued on toprol XL 200mg daily. His imdur dose was
increased to 90mg. He was started on amlodipine.
Cervical spinal stenosis. Patient underwent surgical
decompression by ortho on [**1-11**]. He remained in a soft collar
per orthopedic surgery. Patient likely had underlying cervical
spine osteomyelitis at time of surgery, as explained above.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Patient has a condition where anti-TTG is active
in lung tissue leading to hemoptysis when the patient eats
glutin products. He was maintained on a gluten free diet.
Type 1 Diabetes. Patient's blood sugars were well controlled on
NPH and a humalog insulin sliding scale.
Hepatitis B infection. Patient has a history of hepatitis B. A
hepatitis B viral load was found to be detectable, so patient
was started on lamivudine. His liver function tests remained
normal and he did not complain of abdominal discomfort.
CONTACT: patient and [**Name (NI) **] [**Name (NI) **], wife Phone: [**Telephone/Fax (1) 15210**]
Medications on Admission:
Meds: plavix 75mg daily, isosorbide mononitrate ER 60mg daily,
toprol XL 200mg [**Hospital1 **], cellcept 1000mg [**Hospital1 **], nitro 0.4mg prn,
nystatin s/s, prilosec 40mg daily, ranitidine 300mg qhs,
hydralazine 75mg tid, kayexalate prn, tacro 9mg [**Hospital1 **], trazodone
50-100mg qhs, valcyte 450mg daily, aspirin 325mg daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): If patient not ambulatory.
4. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (FR).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a
day).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Myfortic 360 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
15. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous once a day: AM dose.
16. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous at bedtime.
17. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
20. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q 24H (Every 24 Hours): 750 mg daily through [**2142-2-28**].
21. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
22. Tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO Q12H (every
12 hours).
23. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) as needed for diarrhea.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 42**] Center
Discharge Diagnosis:
Primary:
Severe C3 stenosis with cord compression
Cervical spine osteomyelitis
Hospital acquired pneumonia
Oral candidiasis
Oral herpes simplex virus
Cholelithiasis
Secondary:
ESRD s/p kidney transplant
Type 1 Diabetes
Hypertension
Hyperlipidemia
Coronary artery disease
Peripheral neuropathy
Discharge Condition:
Mild proximal upper extremity weakness (5+ in triceps
bilaterally, 4+ in L deltoid). Right IP 4+, left full strength.
Bilateral foot drop ([**3-2**] in both TA). Significant decrease in
proprioception to the knees bilaterally.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted with increasing weakness and loss of stool.
This was found to be secondary to severe cervical stenosis with
compression of the spinal cord, for which you underwent surgery.
It was discovered that the bone in your spine was infected and
so you were treated with antibiotics (vancomycin).
Additionally, you developed a pneumonia which improved with
antibiotics. You developed mouth pain which was likely
secondary to thrush and oral herpes which improved with
antifungal and antiviral medications. Follow up biopsy was
negative for cmv and herpes.
Your gallbladder was removed laparascopically
IV Vancomycin via PICC line 6 weeks (from [**2142-1-17**] to [**2142-2-28**])
Labs per transplant clinic recommendations. Patient has
appointment on [**2-15**]. Do not give Prograf that morning but send
dose with patient to take following trough prograf lab draw,
Vanco trough, CBC, Chem 10, AST, T bili and U/A
Please send weekly CBC/diff, BUN/Creatinine, and vancomycin
trough to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25**] (fax: [**Telephone/Fax (1) 1021**]).
during your The following medication changes were made
hospitalization:
1. Pregabalin (Lyrica) was increased to 75mg [**Hospital1 **]
2. Please take Vancomycin for 6 weeks (from [**2142-1-17**] to [**2142-2-28**])
5. Please take isosorbide mononitrate at the increased dose of
90 mg daily.
6. Please take amlodipine daily for improved blood pressure
control.
7. Your NPH and humalog doses were changed due to your poor
oral intake as a result of your mouth sores. These medications
should be gradually adjusted as your oral intake improves.
Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4000**], MD Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2142-2-15**] 3:00
[**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**], MD Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2142-2-20**] 11:00
Ortho: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85**] [**Telephone/Fax (1) 809**] on [**2-21**] at 2:00 on
the [**Location (un) 457**] of the [**Hospital Ward Name **] building
You are scheduled to see Dr. [**Last Name (STitle) **] from Neurology on [**2142-3-2**].
Please call [**Telephone/Fax (1) 15211**] with questions.
[**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**], MD Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2142-3-6**] 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4000**] MD [**MD Number(2) 4001**]
Completed by:[**2142-2-10**]
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30,906
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21079+57228
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-10-27**] Discharge Date: [**2106-11-5**]
Date of Birth: [**2041-6-25**] Sex: M
Service: NEUROSURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
metastatic melanoma to brain
Major Surgical or Invasive Procedure:
s/p left frontal-parietal tumor resection, s/p left subdural
hematoma evacuation
History of Present Illness:
65M with PMH metastatic melanoma diagnosed in [**2102**], s/p excision
with local and nodal recurrence s/p ECOG protocol (GM-CSF vs
placebo) and IL2 treatment in [**2104**], who presents with brain
lesions, 1 cm R parietal, 3.5 cm L parietal, diagnosed by MRI
after the patient developed new onset generalized seizures on
[**2106-10-15**].
Past Medical History:
metastatic melanoma ([**2102**]), HTN, cardiomyopathy (EF 24%),
hyperlipidemia, asbestosis, GERD, OSA, depression, DM2, anemia
Social History:
married, non-drinker, non-smoker, does not work
currently
Family History:
CAD, father died at 46y; DM2 sister
Physical Exam:
PHYSICAL EXAM on admission:
T: 96.8 BP: 138/78 HR: 61 R:18 99%RA O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**5-13**] bilaterally, EOMI
Neck: Supple, no lymphadenopathy
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 2+ DP pulses bilaterally.
Neuro-- Mental status: Awake and alert, cooperative with exam,
normal
affect. Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors. Cranial
Nerves: I: Not tested II: Pupils equally round and reactive to
light, 5 to 3 mm bilaterally. Visual fields are full to
confrontation. III, IV, VI: Extraocular movements intact
bilaterally without
nystagmus. V, VII: Facial strength and sensation intact and
symmetric. VIII: Hearing intact to voice. IX, X: Palatal
elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius
normal bilaterally. XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-15**] throughout. No pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally. Coordination: normal on
finger-nose-finger.
ON DISCHARGE:
Mental status changes include: alert and oriented to self,
occasionally "hospital", but never [**Hospital1 18**] or date. Pt speech is
coherent but occasionally pressed and occasional non-sensical.
Understandable words that are incorrect are spoken. CNs,
strength and sensory exam are full and within normal limits as
above.
Pertinent Results:
[**2106-10-27**] 05:48PM GLUCOSE-173* UREA N-38* CREAT-1.4* SODIUM-139
POTASSIUM-3.1* CHLORIDE-97 TOTAL CO2-29 ANION GAP-16
[**2106-10-27**] 05:48PM CALCIUM-9.5 PHOSPHATE-4.1# MAGNESIUM-2.5
[**2106-10-27**] 05:48PM PHENYTOIN-7.1*
[**2106-10-27**] 05:48PM WBC-9.6 RBC-4.20* HGB-12.7* HCT-37.4* MCV-89
MCH-30.3 MCHC-34.0 RDW-17.2*
[**2106-10-27**] 05:48PM PLT COUNT-123*
[**2106-10-27**] 05:48PM PT-11.5 PTT-21.0* INR(PT)-1.0
***************
MR HEAD W/O CONTRAST [**2106-10-28**] 7:23 PM
MR HEAD W/O CONTRAST; -52 REDUCED SERVICES
Reason: +/- gado to assess residual tumor burden
[**Hospital 93**] MEDICAL CONDITION:
65 yo M s/p crani w/ resection likely met melanoma [**10-28**]
REASON FOR THIS EXAMINATION:
+/- gado to assess residual tumor burden
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient is status post surgery for further
evaluation.
TECHNIQUE: T1 sagittal and axial images of the head were
obtained without contrast. The contrast-enhanced study was
planned but the patient was unable to continue, and the
examination was terminated.
FINDINGS: This is a limited study obtained without contrast as
described above. There are postoperative changes seen in the
left posterior temporo- occipital region with areas of blood
products in this region. In addition, small areas of blood
products secondary to metastases are seen in the right posterior
temporal region. A small subdural hematoma is seen on the left
side appears to which it is postoperative in nature. There is no
midline shift or hydrocephalus.
IMPRESSION: Limited study. Postoperative changes as described
above. For further evaluation and evaluation of the
postoperative changes, a repeat study is recommended with
gadolinium.
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2106-10-30**] 11:22 AM
**************
MR HEAD W/ CONTRAST [**2106-10-28**] 5:25 AM
MR HEAD W/ CONTRAST
Reason: L and R parietal lobe tumor
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with h/o metastatic melanoma left parietal lobe
and right parietal lobe. Please do at 4:00 am, OR scheduled for
7:30 am [**10-28**] thank you.
REASON FOR THIS EXAMINATION:
L and R parietal lobe tumor
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with history of metastatic
melanoma, for further evaluation.
TECHNIQUE: T1 sagittal, axial, and coronal images of the brain
were acquired following gadolinium administration. MP-RAGE axial
images were also acquired. Comparison was made with the previous
outside MRI of [**2106-10-18**].
FINDINGS: Again hyperintense/enhancing lesions are identified in
the left temporal-occipital lobe and also in the right posterior
temporal lobe. Overall appearance of the lesion has not
significantly changed compared to the prior study. There is
surrounding edema seen. There is no midline shift, mass effect,
or hydrocephalus.
IMPRESSION: Unchanged appearances of bilateral cerebral masses
in temporal- occipital regions, left greater than right side
compared with MRI of [**2106-10-18**]. The examination was performed for
operative planning.
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2106-10-30**] 11:24 AM
******************
CT HEAD W/O CONTRAST
Reason: eval interval changes
[**Hospital 93**] MEDICAL CONDITION:
65 yo M s/p craniectomy w/ mass resection [**10-28**] continued change
in MS and word finding difficulty
REASON FOR THIS EXAMINATION:
eval interval changes
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: CT of the head.
CLINICAL INFORMATION: Patient with craniectomy with mass
resection.
TECHNIQUE: Axial images of the head were obtained without
contrast. Comparison was made with the previous study of
[**2106-10-28**].
FINDINGS: Again postoperative changes are identified in the left
posterior temporo-occipital region. There are blood products
seen in this region with small amount of air as before. There is
some increased low density seen in this region secondary to
edema. These findings are unchanged from the previous study.
Subtle hyperintensity due to hemorrhagic metastasis is also seen
in the right posterior temporal region, unchanged.
Since the previous study, there is slight increase in the
subdural collection seen in the left frontal region which
appears to be a postoperative subdural collection. There is
slight mass effect also seen on the adjacent sulci. There is
minimal midline shift also identified.
IMPRESSION: New since the previous study is slight increase in
size of the left-sided subdural collection which now measures
approximately 11 mm with mass effect on the adjacent sulci and
slight midline shift. Otherwise, the examination is unchanged.
No new areas of intraparenchymal hemorrhage seen.
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2106-10-30**] 11:21 AM
*****************
MR HEAD W/ CONTRAST [**2106-11-1**] 12:48 PM
MR HEAD W/ CONTRAST
Reason: only POST GADO images are necessary
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with s/p tumor resection will require RT
REASON FOR THIS EXAMINATION:
only POST GADO images are necessary
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL INDICATION: Status post tumor resection, will require
radiotherapy. Evaluate post-gadolinium images.
COMPARISON: [**2106-10-28**].
TECHNIQUE: Non contrast Sagittal, axial, coronal T1, FLAIR, and
post- gadolinium contrast images were obtained. ADC and DWI
images were reviewed.
FINDINGS: There is enhancement along the anterior left temporal
surgical bed that may represent residual tumor focus or could be
in the clinical spectrum of postoperative change. A left
hemispheric subdural fluid collection measuring at most 1.5 cm
from the inner skull is unchanged. There is a 1.1 cm midline
shift to the right, unchanged. A 2mm right hyperintense temporal
lesion is noted, unchanged (14,14 / 15,10). A 2 mm hyperintense
right temporal lesion (14,22 / 15,18) is again visualized and
likely represents a metastatic focus. A subcentimeter
hyperintense focus in the right temporal lobe (14, 14) also
likely represents metastatic focus. A left temporoparietal
craniotomy is noted. A left temporal/parietal wedge- shaped area
demonstrtates restricted diffusion, consistent with acute
infarction.
IMPRESSION:
1. Acute infarct in the left temporal/parietal lobe 2. There are
at least three subcentimeter metastatic foci seen within the
right temporal lobe.
3. Stable left subdural hemorrhage and 1.1-cm midline shift.
4. Enhancement along the anterior portion of the left parietal
lobe may represent post op changes or residual tumor. Recommend
followup imaging for further evaluation.
These results were transmitted to Dr. [**Last Name (STitle) 37564**] by phone at 3:55
p.m. on [**11-1**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**]
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: TUE [**2106-11-2**] 4:51 PM
***************
CT HEAD W/O CONTRAST [**2106-11-2**] 5:18 PM
CT HEAD W/O CONTRAST
Reason: Please perform prior to 6pm. Thanks. Rule out post
operativ
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with subdural evacuation on the left.
REASON FOR THIS EXAMINATION:
Please perform prior to 6pm. Thanks. Rule out post operative
hemorrhage and midline shift.
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL INDICATION: Status post subdural evacuation on the
left, rule out post-operative hemorrhage or midline shift.
COMPARISON: [**2106-10-30**].
NON-CONTRAST CT HEAD: There are previous post-operative changes
in the left posterior temporal occipital region with new left
tempoaro occipital post- surgical changes noted. There is
increased hypodensity in the left frontal lobe (2A, 14). There
is slightly increased pneumocephalus in this area when compared
to prior. The left extra- axial fluid collection is unchanged.
There is stable midline shift.
IMPRESSION: There is subtle loss of [**Doctor Last Name 352**]-white differentiation
and increased hypodensity in the left frontal lobe that raises
the possibility of infarct. This could also be artifactual. If
clinical suspicion of infarct is high would recommend an MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n imaging for further evaluation.
Results were discussed with Chip [**Doctor Last Name **] at 10 PM on [**2106-11-2**]
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: WED [**2106-11-3**] 7:22 AM
Brief Hospital Course:
Admitted on [**10-27**] preoperatively for MRI WAND study. On [**10-28**]
he went to the OR for craniectomy, left parietal tumor excision.
Postoperatively, the pt was transferred to the SICU; his vitals
remained stable, but his ability to name objects and his
orientation was not complete. Intraoperative frozen section,
prelim path: epithelial malignant tumor. Postoperative CT
demonstrated expected post-surgical changes, in addition a 7mm
hyperattenuating focus in the postsurgical bed, ? hemorrhage was
identified.
On POD#1, the morning of [**10-29**], he was more aphasic, and a
repeat CT demonstrated increased edema causing 7mm MLS;
dexamethasone was increased and he remained in the ICU.
On POD#2, [**10-30**], the pt was stable, and on POD#3, [**10-31**], he was
transferred to the floor.
On POD#4, the pt was noted to be increasingly somnolent, and MRI
this day, [**11-1**], demonstrated post-surgical changes including
left temporoparietal craniotomy with wedge-shaped infarct within
the left parietal lobe. Three subcentimeter metastatic foci
seen within the right temporal lobe. Stable appearance of left
hemispheric subdural hemisphere with associated 1.1-cm midline
shift.
On POD#5, [**11-2**], the SDH was evacuated. Post-op he regained his
alertness, but remained aphasic with difficulty finding words.
He was oriented to person, and occasionally place. Routine
post-op CT showed the loss of [**Doctor Last Name 352**]-white differentiation and
increased hypodensity in the left frontal lobe; ? new bleed R
occipital lobe.
POD#[**6-17**], the pt was seen by radiation oncology, and follow up
was arranged with providers in [**State 1727**] at the wife's request.
Physical therapy recommended rehab and he was deemed safe for
discharge on [**2106-11-5**].
Medications on Admission:
All: NKDA
[**Last Name (un) 1724**]: quinapril 20 qd, lipitor 10 qd, carvedilol 12.5 [**Hospital1 **],
coenzyme Q qd, potassium, isordil 40 tid, lasix 40 qd, dilantin
200 qam/300 qpm, clonazepam 0.5 [**Hospital1 **], decadron 4 [**Hospital1 **], glipizide 5
qd, famotidine 20 [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Coenzyme Q10 Oral
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO Q AM.
6. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO Q PM.
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Quinapril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
13. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
14. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
clover manor Skilled nursing facility
Discharge Diagnosis:
Metastatic melanoma
Brain metastases
Discharge Condition:
stable, disoriented
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:
YOUR SUTURES SHOULD BE REMOVED ON [**11-16**]. IF YOU CAN RETURN
TO THE OFFICE, PLEASE DO SO, OTHERWISE A QUALIFIED HEALTH CARE
PROVIDER CAN REMOVE THEM.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN BRAIN [**Hospital **] CLINIC AFTER YOU RECEIVE
WHOLE BRAIN RADIATION TREATMENT.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST.
YOU WILLNEED AN MRI OF THE BRAIN WITH GADOLIDIUM.
YOU HAVE A SCHEDULED APPOINTMENT WITH DR. [**Last Name (STitle) 55962**] [**Name (STitle) **] AT
[**Hospital6 **] CENTER ON [**11-11**] AT 2:45PM.
YOU HAVE SCHEDULED APPOINTMENT WITH DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT [**State 55963**] CENTER NEXT WEEK. CALL [**Telephone/Fax (1) 55964**] TO CONFIRM
TIME AND DATE. AT THIS APPOINTMENT DR. [**Last Name (STitle) **] WILL ARRANGE
YOUR SCHEDULE FOR WHOLE BRAIN RADIATION TREATMENT.
Completed by:[**2106-11-5**] Name: [**Known lastname 588**],[**Known firstname **] Unit No: [**Numeric Identifier 10536**]
Admission Date: [**2106-10-27**] Discharge Date: [**2106-11-5**]
Date of Birth: [**2041-6-25**] Sex: M
Service: NEUROSURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 3656**]
Addendum:
Patient had a foot ulcer on the right foot and the wound care
nurse recommended that podiatry see the patient. Please
follow-up with podiatry as an outpatient for your foot ulcer.
Discharge Disposition:
Extended Care
Facility:
clover manor Skilled nursing facility
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**]
Completed by:[**2106-11-5**]
|
[
"250.00",
"401.9",
"428.20",
"E878.8",
"501",
"707.14",
"172.9",
"425.4",
"327.23",
"198.3",
"285.9",
"272.4",
"428.0",
"530.81",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"00.32",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
18261, 18482
|
11657, 13437
|
304, 386
|
15361, 15383
|
2701, 3295
|
16756, 18238
|
999, 1037
|
13782, 15193
|
10131, 10185
|
15301, 15340
|
13463, 13759
|
15407, 16733
|
1052, 1066
|
2355, 2682
|
236, 266
|
10214, 10511
|
414, 756
|
10520, 11634
|
1080, 1371
|
1386, 2341
|
778, 907
|
923, 983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,302
| 146,719
|
16206
|
Discharge summary
|
report
|
Admission Date: [**2146-3-20**] Discharge Date: [**2146-4-2**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
woman who was transferred from [**Hospital 16843**] Hospital after
several hours of posterior and anterior headaches sustaining
the worst headache of her life. Denied fever, nuchal
rigidity, blurry vision, or vomiting.
CT scan shows diffuse subarachnoid hemorrhage. The patient
was transferred to [**Hospital3 **] for further evaluation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Osteoarthritis.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: On physical exam, the patient was
afebrile, pulse 72, blood pressure 160/72, respiratory rate
14, and sats 100%, intubated. The patient was sedated and
intubated. Pupils were 2 mm and minimally reactive. Chest
was clear to auscultation. Cardiovascular: Regular, rate,
and rhythm, abdomen is soft, nontender, nondistended.
Extremities: No clubbing, cyanosis, or edema. Neurologic
examination: Patient was localizing with the bilateral upper
extremities, withdrawing the lower extremities, and pupils
were trace reactive.
The patient was on CPAP with pressure support. Was admitted
to the Neurologic Intensive Care Unit, where ventricular
drain was placed without complication. On [**2146-3-21**], the
patient underwent an angiogram which showed patient had a
posterior communicating artery aneurysm for which she was to
receive coiling procedure.
On [**2146-3-23**], the patient was not opening her eyes to
sternal rub, localizing on the right and left. Moving feet
spontaneously, but was not following commands. She was scheduled
for arteriogram with possible coiling of the left PCOM aneurysm.
The patient underwent this procedure on [**2146-3-23**] which was
complicated by intraprocedural perforation of the aneurysm with
extravasation of blood into the cisterns which was decompressed
by the existing EVD. The anticoagulation was immediately
reversed and the coiling was continued until the aneurysm was
sealed. A new EVD was placed on the contralateral side which
returned an ICP in the low teens range. Postprocedure
the patient was intubated and sedated. Pupils were 4 down to
3 mm. Corneals were present, no withdrawal of the upper
extremities. She had no groin hematoma. She had palpable
dorsalis pedis pulses. Neurologically, she was difficult to
assess secondary to sedation, but she remained intubated and
sedated.
On [**2146-3-24**], the patient opens her eyes minimally to
vigorous stimulation. Pupils right was larger than the left.
She did not attend to visual stimulation. She would not
follow commands. She was localizing to pain. She remained
intubated and sedated.
Postprocedure course was complicated by fevers and pneumonia,
and despite the best efforts, her neurologic examination
failed to improve although a CT showed no hemispheric or
territorial infarcts. The family decided to make the patient
comfort measures only, and the patient passed away on [**2146-4-2**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2146-5-26**] 11:17
T: [**2146-5-26**] 11:26
JOB#: [**Job Number 46240**]
|
[
"401.9",
"430",
"285.1",
"998.2",
"331.4",
"E878.8",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.72",
"02.2",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
641, 3317
|
154, 526
|
548, 618
|
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