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70,180
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|
38038
|
Discharge summary
|
report
|
Admission Date: [**2132-7-24**] Discharge Date: [**2132-7-27**]
Date of Birth: [**2071-2-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Chief Complaint: epigastric pain
Reason for MICU transfer: GIB w/ tachycardia
Major Surgical or Invasive Procedure:
Endotracheal intubation
EGD w/ variceal banding
History of Present Illness:
Mr. [**Known lastname 4427**] is a 60 year old man with h/o HCC, s/p TACE x3,
recent EGD showing esophageal varices, who presents with
melanotic stool x 3 days.
The patient presents with epigastric burning abdominal pain and
melanotic stools x 2 days. Patient reports sudden onset of
epigastric abdominal pain approximately 2 days ago. Burning in
sensation. No radiation. Associated SOB from pain. No n/v/d. No
hematemesis. Black stools. No BRPBPR. Pain worse over the past 2
days. No f/c. No CP. No dysuria. Drank yesterday
Of noted, Mr. [**Known lastname 4427**] was seen in clinic yesterday for evaluation
of TACE x 4 and was noted to be intoxicated and hypertensive
(190/110) on presentation. The patient reported drinking all day
and not taking his BP meds. The patient was urged to go to the
ED for evaluation, but he however left AMA.
In the ED, initial VS were: 97.4 126 165/91 15 98% RA. Initial
exam revealed maroon colored stools, grossly guaic positive.
Laboratory date revealed hct 29.5 (baseline 33), wbc 3.5, plts
50, tbili 2.1 and LFTs otherwise above baseline and lactate of
9.9. Chem 10 was significant for AG 23 and normal renal
function. A serum alcohol level was 133 and tox otherwise
negative. A UA was negative for acute infection and demonstated
urine ketones. A bedside ultrasound revealed no evidence of
ascites. He was tachycardic but not hypotensive. Hepatology was
consulted and recommended CT abd/pelvis to evaluate for source
of lactate acidosis which demonstrated no acute bowel pathology
although suggestion of increased portal venous clot burden was
noted. A multiphasic liver MRI was ordered to better evaluate.
A CXR revealed no acute process. Access 2 18g PIVs were placed.
The patient was admitted to the MICU 6 ICU per request of
hepatology for possible urgent scope.
On arrival to the MICU, initial vitals were: 99.2 119 117/92
99% RA 22.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
HCC s/p TACE x 3, most recently on [**2131-9-3**]
Alcoholic cirrhosis with signs of portal hypertension with
grade 1 varices and one episode of jaundice.
GERD with erosive gastritis
HTN
MGUS
Social History:
- Tobacco: none
- Alcohol: currently drinking every few days, 2-3beers/day, no
h/o withdrawal or seizures
- Illicits: none
- Housing: Lives alone. Has a brother and sister that live
nearby.
Originally from [**Country **].
Family History:
He had a father with prostate cancer. No other cancer history
in the family.
Physical Exam:
On admission:
Vitals: 99.2 119 117/92 99% RA 22
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
.
On discharge:
VITALS: T:98.9 Tc: 98l.2 BP:138/95 HR:66 RR:18 O2: 100%RA
I/O: 1200 I / NR O BMx3 1 guiaic positive brown stool
Not [**Doctor Last Name **] on CIWA scale
GEN: African American male, NAD
HEENT: Sclera anicteric, moist membranes
CV: S1, S2 regular rhythm, normal rate
LUNGS: Unlabored respirations, CTA bilaterally
ABD: distended, soft, non-tender
EXT: peripheral pulses palpable, no edema
NEURO: oriented to self, location, date, very mild asterixis
Pertinent Results:
On admission:
.
[**2132-7-24**] 01:01AM BLOOD WBC-3.5* RBC-3.33* Hgb-8.9* Hct-29.6*
MCV-89 MCH-26.8* MCHC-30.2* RDW-20.0* Plt Ct-50*#
[**2132-7-24**] 04:54AM BLOOD PT-16.4* PTT-32.5 INR(PT)-1.5*
[**2132-7-24**] 01:01AM BLOOD Glucose-119* UreaN-20 Creat-0.8 Na-141
K-3.5 Cl-100 HCO3-17* AnGap-28*
[**2132-7-24**] 01:01AM BLOOD ALT-72* AST-192* AlkPhos-171*
TotBili-2.1*
[**2132-7-24**] 06:25AM BLOOD Calcium-7.7* Phos-2.0* Mg-1.2*
[**2132-7-24**] 01:01AM BLOOD Albumin-3.4*
[**2132-7-24**] 01:01AM BLOOD ASA-NEG Ethanol-133* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2132-7-24**] 02:59AM BLOOD Lactate-9.9*
.
On discharge:
[**2132-7-27**] 05:45AM BLOOD WBC-3.1* RBC-3.32* Hgb-9.4* Hct-30.1*
MCV-91 MCH-28.2 MCHC-31.2 RDW-21.2* Plt Ct-69*
[**2132-7-27**] 05:45AM BLOOD PT-14.7* PTT-26.3 INR(PT)-1.4*
[**2132-7-27**] 05:45AM BLOOD Glucose-115* UreaN-8 Creat-0.8 Na-138
K-3.1* Cl-105 HCO3-27 AnGap-9
[**2132-7-27**] 05:45AM BLOOD ALT-48* AST-107* LD(LDH)-326*
AlkPhos-132* TotBili-1.7*
[**2132-7-27**] 05:45AM BLOOD Albumin-2.9* Calcium-7.4* Phos-2.5*
Mg-1.8
.
CT A/P:
IMPRESSION:
1. Propagation of nonocclusive left portal thrombus, now also
involving the right/main portal and superior mesenteric veins.
2. Cirrhosis and mild ascites.
3. Proctitis.
.
CXR:
IMPRESSION: No acute cardiopulmonary process. Low lung
volumes.
.
EGD:
Esophagus:
Protruding Lesions 3 cords of grade II varices were seen in the
lower third of the esophagus. There were stigmata of recent
bleeding. 3 bands were successfully placed.
Stomach:
Other red blood seen in the stomach without any site of active
bleeding.
Duodenum: Normal duodenum.
Impression: Varices at the lower third of the esophagus
(ligation)
Red blood seen in the stomach without any site of active
bleeding.
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname 4427**] is a 60 year old man with h/o HCC, s/p TACE x3,
recent EGD showing esophageal varices, who presents with
melanotic stool x 3 days concerning for recurrent variceal
bleed.
# GIB: Hct on arrival was 29.5 (bl of 33). Lactate was elevated
to 9.9. CT-A/P showed propagation of portal venous clot.
Hepatology was consulted out of concern for variceal bleed. He
was intubated for endoscopy upon arrival to the ICU and began to
have blood suctioned from his mouth. Urgent endoscopy was
performed while he received 2U PRBCs (emergency release).
Femoral line was placed. 3 cords of grade II varices were seen
w/ recent stigmata of bleeding. 3 bands were placed. He remained
hemodynamically stable thereafter and was extubated. Hct
stabilized. He was started on ceftriaxone, octreotide x 48
hours, pantoprazole, and carafate. Nadolol was continued. He was
discharged on cipro for a seven day course, PPI, carafate, and
nadolol.
.
# Elevated lactate: Initially presented with an anion gap
acidosis in the setting of GIB. No evidence of bowel ischemia
from hypoperfusion on prelim CT scan, however, has thromosis
down to SMV. Improved after resuscitation. Would expect some
lactate to not clear in light of cirrhosis.
.
# EtOH cirrhosis: Known esophageal varices, prior GIBs, now
decompensated with recurrent bleed. Patient continues to drink
and presented with EtOH level 133. Nadolol was restarted at 60
mg qday, and rifaximin and lactulose were started. He was placed
on MVI, thiamine, folate, and iron. CIWA scale was ordered as
well out of concern for withdrawal.
.
# PVT: No evidence of bowel ischemia on the CT, however, has
thrombosis down to SMV. Not a candidate for anticoagulation of
the PVT given recent bleeding.
.
# HCC: s/p TACE x3: Interval increase in the number of
arterially enhancing lesions in segment IV on MRI [**2132-5-10**]
compared to those on MRI [**2132-2-6**]. Currently undergoing w/u for
TACE # 4.
.
Communication was with [**Name (NI) **] [**Name (NI) 84962**] friend [**Telephone/Fax (1) 84963**]. Code
status was Full code.
.
TRANSITIONAL ISSUES
-Repeat EGD in 3 weeks to evaluate status of varices
-Ciprofloxacin can be discontinued after four more days (total
seven day course)
Medications on Admission:
Medications:
1. lactulose 10 gram/15 mL Syrup (30) ML PO TID
2. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
3. nadolol 20 mg Tablet 3Tablet PO DAILY
4. multivitamin Oral
5. sucralfate 100 mg/mL Suspension (30) mL PO twice [**Hospital1 **]
6. folic acid 1 mg Tablet One (1) Tablet PO once a day.
7. iron Oral
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *Cipro 500 mg twice a day Disp #*8 Each Refills:*0
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Multivitamins 1 TAB PO DAILY
5. Nadolol 60 mg PO DAILY
Hold for SBP<90 or HR<55.
6. Rifaximin 550 mg PO BID
RX *Xifaxan 550 mg twice a day Disp #*60 Each Refills:*0
7. Sucralfate 1 gm PO QID
8. esomeprazole magnesium *NF* 40 mg Oral [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Variceal GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 4427**]. You
were admitted to [**Hospital1 18**] with GI bleed. You underwent an upper
endoscopy that showed esophageal varices with evidence that
there was recent bleeding. Several bands were successfully
placed to these varices. You were monitored for several days and
there was no recurrent bleeding.
Please continue your home medications with the following
changes:
1. Start taking ciprofloxacin
2. Start taking rifaxamin
3. Increase frequency of nexium to twice a day
Followup Instructions:
Department: LIVER CENTER
When: TUESDAY [**2132-7-29**] at 3:40 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/BMT
When: FRIDAY [**2132-8-8**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 3237**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2132-8-8**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3150**], MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,446
| 111,173
|
45879
|
Discharge summary
|
report
|
Admission Date: [**2201-2-14**] Discharge Date: [**2201-2-23**]
Date of Birth: [**2146-4-3**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Aspirin / Codeine / Lipitor
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
1. Right Femoral Line
History of Present Illness:
54F w/HTN, CAD s/p CABG, MV repair, AVR on coumadin, hemolytic
anemia [**12-31**] valve s/p mechanical fall with trauma to leg and
chest in setting of elevated INR 6.7 (checked at PCPs office)
admitted 2 days after fall with persistent L knee pain and
hematoma on head/L chest wall. On admission, patient's INR had
fallen to 2.7; however, given fall in setting of elevated INR,
but had a trauma evaluation including CT head, spine, Abd/pelvis
and LLE without evidence of bleed or fracture. At the time, she
was admitted for pain control and monitoring of hematocrit
(34.6-->31.9). Of note, patient has a h/o HTN; on admission was
noted to have low BPs (usual SBP 140-160s, on admission SBP
100), but was asymptomatic (no LH/dizziness/CP/SOB/fatigue).
Past Medical History:
CAD LVEF > 50% s/p CABG '[**95**] and stents
AVR '[**95**]; MV ring-annuloplasty
HTN
Hyperlipidemia
Hypothyroidism [**12-31**] iodine tx for [**Doctor Last Name 933**] dz
Depression with psychosis
Discoid lupus
PTSD
H/o carcinoid s/p resection in '[**73**]
COPD
TAH b/l SBO
Hemolytic anemia [**12-31**] AVR
Migraine
T9-T10 disk herniation
Social History:
no ETOH, smokes 1ppd.
Family History:
Father, healthy, in his 80s. Mother, 73, deceased, had DM HTN.
Sister died at age 47 from MI. Brother died from liver
cirrhosis.
Physical Exam:
96.1, 103, 95-117/66-80, 18, 100%RA
GENL; mildly uncomfortable
HEENT: CN II-XII grossly in tact, OP clear, no thyromegaly
CV: RRR +click, +systolic murmur
Lungs: CTA
ADB: obese, nt, nd, +bs
EXT: tender R knee and R lower leg. Most tender in popliteal
fossa. Able to minimally bend knee to 20 degress lmtd by pain.
Also has pain with passive motion. 2+ distal pulses. Non
erythematous.
Pertinent Results:
Admission Labs:
[**2201-2-14**]: 1:15pm Hct 34.6
[**2201-2-15**]: 07:00am Hct 31.9, INR 2.9, PTT 42.1
[**2201-2-15**]: 6:00pm Hct 30.0
*
Chemistries: GLUCOSE-94 UREA N-21* CREAT-1.4* SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
*
Radiologic Studies-
CT left knee: No evidence of hemarthrosis or fracture of the
left knee.
*
CT head: No acute hemorrhage or mass effect.
*
C-Spine: 1) No fracture or malalignment 2) Multilevel
degenerative changes.
*
CT abd/Pelvis: No evidence of acute traumatic injury on limited
noncontrast evaluation.
*
Femur/Tib Fib Plain Films: Negative for fracture
*
CXR PA/LAT [**2-17**]: Bilateral plate-like atelectasis at the lung
bases, left greater than right. Underlying pneumonia within
atelectatic lung cannot be excluded.
*
CXR PA/LAT [**2-19**]: No signs of acute or chronic parenchymal
infiltrates are present and the lateral and posterior pleural
sinuses are free. The on previous examination, ([**2-17**]) identified
bilateral plate atelectasis have resolved completely.
*
ECHO: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. LVEF>50%. mechanical aortic valve
prosthesis is present. The transaortic gradient is normal for
this 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. A mitral
valve annuloplasty ring is present. There is a minimally
increased gradient consistent with trivial MS. [**Name13 (STitle) **] MR. Moderate
[2+] TR. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion
Brief Hospital Course:
54 y/o female with CAD, mechanical AVR, MVannuloplasty, on
coumadin, who was admitted for pain control s/p fall with
hospital course c/b hypotension and hematocrit drop of unclear
etiology requiring [**Name (NI) 153**] overnight observation. Subsequently
remained hemodynamically stable.
1. Hypotension: On admission the patient was found to have a
blood pressure in 100's systolic. She was otherwise asymptomatic
(no lightheadedness, dizziness, dyspnea or chest pain). However,
of concern is that she normally has poorly controlled
hypertension and she remained with low systolic BP's off all
anti-hypertensives. Aggressive work up was performed to rule out
bleed given her recent fall. She was guaiac negative on exam. CT
scan of the thigh and pelvis were performed which showed no
evidence of bleed. CT head on admission was also negative for
bleed. It was suspected that her hypotension might be secondary
to opiate analgesics she recieved on admission, therefore opioid
analgesics were discontinued. However BP's remained low. SBP
decreased to the 80's-90's and she was given NS prn boluses to
maintain BP >100. She initially responded well to boluses, but
SBP then fell to 70's systolic. During her hospitalization, her
BPs remained on the low side and required prn NS boluses. Her
hematocrits were also being followed. Afternoon of [**2-17**], patient
was found to have a SBP 70s. Patient awake/alert but diaphoretic
and given 250cc NS bolus. Had an EKG which showed a new RBBB.
Right femoral line placed and given 2L NS but SBP remained in
the 80s with good UOP (1000cc after foley placed). Given her
history of significant cardiac disease and new RBBB, cardiology
was consulted and a stat bedside echo was performed to r/o
cardiogenic shock, which was unchanged from prior echo. Pt was
transferred to the [**Hospital Unit Name 153**] for hemodynamic monitoring.
In the [**Hospital Unit Name 153**], hematocrit that was checked showed drop 29.7 to
25.9. Etiology of hematocrit drop was unclear as on admission
patient had full work up which was negative for hematoma. [**Hospital Unit Name 153**]
team wanted to perform an NG lavage to r/o GI bleed, but patient
did not want this done. She was transfused 1 upRBC. (Of note,
she developed T 103 mid-transfusion; blood was sent for
transfusion reaction. She was later transfused a full unit of
RBCs). Despite low BPs, patient continued to mentate and have
brisk UOP, suggesting adequate end organ perfusion. She had a
[**Last Name (un) 104**] stim test to r/o adrenal insufficiency as cause for her
hypotension, which was normal. Pt did have a mild temperature
and sepsis was entertained as possible etiology of hypotension.
CXR showed vague RLL infiltrate, and she was started on empiric
vancomycin/levofloxacin pending culture data. She remained
stable overnight, with stable blood pressure and hematocrit and
was transferred back to the medicine service.
On return to the medicine service her blood pressures gradually
normally, trending upwards to 120's systolic of
anti-hypertensives. Her blood pressure meds may be re-started as
outpatient as her BP/HR tolerates. She subsequently remained
afebrile and HD stable, with cultures negative, suggesting
against infectious etiology of her hypotension. In addition,
repeat CXR PA and Lat showed resolution of vague RLL infiltrate.
Vancomycin was discontinued and she will complete a seven day
course of levofloxacin on [**2-24**].
2. Anemia- The patient has a noted history of hemolysis
secondary to mechanical valve. Her LDH on admission was mildly
elevated w/ Haptoglobin less than 20. However, her levels were
not significantly elevated from baseline to suggest this as the
cause of her acute hematocrit drop. As mentioned she had no
evidence of bleed by multiple CT studies. Her hct drop may have
been dilutional secondary to recieving aggressive IVF repletion
with her hypotension. Following her transfusion in the ICU, her
hematocrit remained stable at 30 and she required no further
transfusions.
3. Mechanical AVR-Given her risk of thrombosis, in setting of no
obvious bleeding, she was re-started on anti-coagulation. She
was started on IV heparin since her INR was sub-therapeutic and
she was continued on this until her INR was greater than 2 on
coumadin.
4. CAD- Known CAD s/p CABG with recent Cath in [**9-1**] with stents
X 4 to RCA/RPDA. She had a new RBBB seen on EKG but stat ECHO
showed no new changes from previous and she was not felt to have
acute MI or cardiogenic shock. She remained chest pain free
throughout her course. Continued on plavix, lipitor. Plan to
re-start atenolol once blood pressure tolerates.
5. Left Leg Pain s/p Fall: No evidence of fracture or hematoma.
Given reported history of multiple falls recently, she was
evaluated by physical therapy service who felt inpatient rehab
was necessary for physical conditioning. She was set up for
placement to rehab center upon discharge. Pain was controlled
with tylenol and low-dose oxycodone prn. Avoided long-acting
opioids given her hypotensive episodes.
6. LLL pneumonia: Initial evidence of pneumonia by CXR vs
atelectasis. She was started empirically on Levo/Vanco. However
subsequent CXR 2 days later showed no evidence of pneumonia. She
was taken off vancomycin at that point and should complete her
7th day of levofloxacin on [**2-24**].
Medications on Admission:
Imdur
COumadin 3 mg
Albuterol IH
Ambien 5 mg QHS
Atenolol 25 mg daily
Clonazepam 2mg PRN
Lipitor 10 mg QD
Plavix 75
Percocet
Oxycontin 20 mg [**Hospital1 **]
HCTZ 25 mg QD
syntroid 125 mcg QD
Protonix 40 mg QD
Lisinopril 40 mg QD
Folate 5 mg daily
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) 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. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Left leg pain
Secondary Diagnoses:
1. [**Name (NI) **] unclear etiology
2. Chronic Hemolytic Anemia
3. Mechanical Aortic Valve
4. Hypothyroidism
5. Multiple falls
Discharge Condition:
Good. Hemodynamically stable. Needs continued physical therapy
rehabilitation.
Discharge Instructions:
You are being discharged to Rehab. Report any medical complaints
to your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**] following discharge.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 665**] in [**11-30**] weeks after discharge
from rehab. Call to make an appointment at [**Telephone/Fax (1) 250**].
*
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 11216**] Date/Time:[**2201-4-17**] 1:00
|
[
"V45.82",
"427.31",
"416.8",
"E884.4",
"V45.81",
"920",
"922.1",
"283.19",
"790.92",
"999.8",
"496",
"414.00",
"285.1",
"V58.61",
"924.00",
"276.5",
"401.9",
"458.9",
"V58.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10225, 10295
|
3774, 9121
|
324, 348
|
10525, 10605
|
2096, 2096
|
10829, 11196
|
1546, 1676
|
9419, 10202
|
10316, 10316
|
9147, 9396
|
10629, 10806
|
1691, 2077
|
10374, 10504
|
276, 286
|
376, 1129
|
2447, 3751
|
2112, 2438
|
10335, 10353
|
1151, 1491
|
1507, 1530
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,917
| 149,229
|
13841
|
Discharge summary
|
report
|
Admission Date: [**2196-11-28**] Discharge Date: [**2196-12-4**]
Date of Birth: [**2136-5-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x4: Left internal mammary
artery to left anterior descending artery, and saphenous
vein grafts to obtuse marginal, ramus and right coronary
arteries on [**2196-11-30**]
s/p cardiac cath
History of Present Illness:
60 year old male with CAD s/p PCI in [**2189**] who waa admitted to an
OSH with neck burning radiating down his right arm. [**Last Name (un) **] to
his previous angina. Transferred for cath that showed severe
coronary artery disease. Cardiac surgery was consulted regarding
surgical revascularization
Past Medical History:
CAD
s/p PCI
Hypertension
Dyslipidemia
Gerd
Anxiety
Angina
Social History:
Quit smoking seventeen years ago with a 22 pack year history.
Family History:
Positive for early CAD
Physical Exam:
VS: 98.2 116/72 72 20 94% RA
Pleasant, answers questions appropriately
Chest: Lungs clear bilaterally. Mild erythema circumferentiall
around sternal incision. Dry and inact without drainage
Cor: regular without murmurs
Abdomen: soft and nontender without rebound or guarding
Extremities: 1+ edema bilaterally
EVH site: left leg, soft and stable
Pertinent Results:
[**2196-12-3**] 06:45AM BLOOD WBC-8.3
[**2196-12-2**] 05:18AM BLOOD WBC-12.4* RBC-3.93* Hgb-12.3* Hct-34.9*
MCV-89 MCH-31.2 MCHC-35.2* RDW-13.0 Plt Ct-150
[**2196-11-28**] 12:40PM BLOOD WBC-6.9 RBC-4.92 Hgb-15.1 Hct-42.8 MCV-87
MCH-30.7 MCHC-35.4* RDW-12.7 Plt Ct-208
[**2196-12-2**] 05:18AM BLOOD Plt Ct-150
[**2196-11-30**] 02:06PM BLOOD PT-15.0* PTT-36.7* INR(PT)-1.3*
[**2196-11-28**] 12:40PM BLOOD PT-13.1 PTT-34.9 INR(PT)-1.1
[**2196-12-3**] 06:45AM BLOOD UreaN-19 Creat-0.9 Na-134
[**2196-12-2**] 05:18AM BLOOD Glucose-126* UreaN-21* Creat-1.0 Na-133
K-4.9 Cl-99 HCO3-25 AnGap-14
[**2196-11-28**] 12:40PM BLOOD Glucose-104 UreaN-16 Creat-1.0 Na-140
K-4.2 Cl-104 HCO3-29 AnGap-11
[**2196-11-28**] 12:40PM BLOOD %HbA1c-6.1*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 41553**]
(Complete) Done [**2196-11-30**] at 12:00:04 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2136-5-24**]
Age (years): 60 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 427.31, 440.0
Test Information
Date/Time: [**2196-11-30**] at 12:00 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 #: 2008AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.8 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.2 cm
Findings
LEFT ATRIUM: Marked LA enlargement. Elongated LA. Mild
spontaneous echo contrast in the body of the LA. No spontaneous
echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20
cm/s) LAA ejection velocity. All four pulmonary veins identified
and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. A prominent Chiari
network is present (normal variant). No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully excluded. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Moderately dilated
ascending aorta. Mildly dilated aortic arch. Simple atheroma in
aortic arch. Mildly dilated descending aorta. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Physiologic MR (within normal
limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. The rhythm appears to be atrial fibrillation. Results
Conclusions
PRE BYPASS The left atrium is markedly dilated. The left atrium
is elongated. Mild spontaneous echo contrast is seen in the body
of the left atrium. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium/left atrial appendage or the
body of the right atrium/right atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are 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%). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is moderately
dilated. The aortic arch is mildly dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is now in sinus rhythm. There is normal
right ventricular systolic function. There is low normal left
ventricular systolic function - EF approximately 50%. There are
no other changes from the pre-bypass study. The thoracic aorta
appears intact.
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) **] [**2196-11-30**] 14:03
Brief Hospital Course:
Patient was admitted to the Cardiac surgery service from the
cath labe where catheterization confirmed severe coronary artery
disease. He was worked up in the usual preoperative manner and
was brought to the OR with Dr [**First Name (STitle) **] on [**2196-11-30**] to undergo
bypass surgery. Please see operative note for full details.
Post-operatively he was admitted to the CVICU for invasive
hemodynamic monitoring. He was weaned from his drips and was
extubated by POD 1. On POD 2 he was transferred to the step dow
floor. Physical therapy was consulted to work on strength and
balance. He was gently diurseed towards his preoperative weight.
On POD 4 he was stable and cleared to be discharged to home.
Medications on Admission:
Atenolol 50'
Plavix 75'
diltiazem 120'
fluoxetine 20 '
lisinopril 5'
prilosec 20'
simvastatin 80'
asa 325'
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
CAD
Hypertension
Dyslipidemia
anxiety
GERD
s/p PCI
Tourette's
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr. [**Last Name (STitle) 11493**] in 1 week please call for appointment
Dr.[**Last Name (STitle) 6955**] in [**1-17**] weeks ([**Telephone/Fax (1) 22629**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2196-12-4**]
|
[
"599.0",
"756.89",
"530.81",
"414.01",
"401.9",
"272.4",
"E878.2",
"413.9",
"427.31",
"368.16"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8882, 8929
|
7098, 7808
|
288, 518
|
9035, 9042
|
1433, 7075
|
9554, 10073
|
1025, 1049
|
7966, 8859
|
8950, 9014
|
7834, 7943
|
9066, 9531
|
1064, 1414
|
239, 250
|
546, 849
|
871, 930
|
946, 1009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,964
| 159,289
|
54636
|
Discharge summary
|
report
|
Admission Date: [**2101-7-21**] Discharge Date: [**2101-7-28**]
Date of Birth: [**2072-4-9**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
[**2101-7-21**]- cerebral angiogram with embolization of tumor
[**2101-7-22**]- Bicoronal craniotomy for tumor excision
History of Present Illness:
Mr [**Known lastname 39606**] initially presented for consultation for a brain
tumor. He has a history of constant headaches and constant
pressure in the head which has
been present over the last few months. Recently, which has
increased in intensity. He also has had some memory problems
and difficulty speaking, all of which have been intermittent. He
has not had any loss of consciousness and no focal weakness.
Imaging revealed a porcine meningioma. It was recommended that
he undergo an angiogram to evaluate the vasculature and possible
embolization with subsequent craniotomy and resection.
Past Medical History:
heart murmur
febrile seizure as infant
Social History:
single, no current tobacco, social etoh
Family History:
non-contributory
Physical Exam:
On examination, he was awake, alert, oriented x3. His pupils
are
equal and reacting to light. The right may be slightly bigger.
Extraocular movements are full. His facial sensation is intact.
Face is symmetric bilaterally. Hearing was intact bilaterally.
Palate elevation is symmetric. Shoulder shrug is symmetric.
Motor strength is [**5-14**] in all four extremities. There is no
pronator drift. Reflexes are 2+/4 and symmetric. There was no
clonus.
Discharge exam:
- AOX3, PERRL, face symmetric, tongue midline
- Wound - with staples clean/dry/intact
- Strength - bil AT/G/[**Last Name (un) 938**] [**3-14**], b/l q/h/il [**5-14**]
Pertinent Results:
[**2101-7-22**] Head CT without Contrast: Expected postoperative
pneumocephalus and trace hyperdensity in the surgical resection
cavity. Small amount of hypoattenuation in the left frontal
subcortical white matters likely reflect preexisting peritumoral
edema, but could be further assessed on followup exams to
exclude infarct. Assessment for tumor is limited.
[**2101-7-23**] Head MRI:
1. Residual tumor at the vertex, in proximity to the superior
sagittal sinus and the adjacent venous tributaries. Follow up
as clinically indicated.
2. Post-surgical changes as described above. Thin rim of slow
diffusion at the posterior margin of the surgical resection
site may relate to changes from ischemia/infarction. No large
infarct and no mass effect.
[**2101-7-23**] Head CT without Contrast: Unchanged examination with
unchanged pneumocephalus and hyperdensity in the resection
cavity and left greater than right frontal peritumoral edema.
[**2101-7-23**] MRV: Nonvisualization of the mid portion of the
superior sagittal sinus, not significantly changed compared to
the preoperative study. Other details as above. Correlate
clinically to decide on the need for further workup.
[**2101-7-24**] EEG: **pending** (prelim - no seizure activity)
[**2101-7-26**] - UNIs - Echogenic material in the central right
internal jugular vein
likely related to a combination of minimal non-flow-limiting
thrombus and
possible mild endothelial injury from recent line placement.
[**7-28**] CT head -
Brief Hospital Course:
Pt electively presented on [**7-21**] and underwent a cerebral
angiogram and embolization of his tumor using coils and onyx.
This was done without complication. He was extubated and
transferred to the ICU for close neurological monitoring. He was
continued on Keppra and Decadron was increased to 4mg q6hr. A
CTV and MRI Wand were ordered for preop planning.
On [**7-22**], The patient went to the operating room for a craniotomy
for resection of a mass. The procedure was of long duration,
but uncomplicated. At conclusion of the case, the patient was
extubated and transported tot he PACU. He was placed on decdron
for prevention of edema. Post-operative CT scan demonstrated
expected postoperative pneumocephalus and trace hyperdensity in
the surgical resection cavity with small amount of
hypoattenuation in the left frontal subcortical white matter,
reflects preexisting peritumoral edema. On examination, the
patient was found to have weakness of the bilateral lower
extremities.
On [**7-23**], the patient underwent MRI, which revealed residual
tumor at the vertex, in proximity to the superior sagittal
sinus and the adjacent venous tributaries. Patient's Foley
catheter was removed, his diet advanced, and JP drain removed.
As patient had poor po intake, he received a 500 mL NS bolus and
his IV fluids increased to 100 mL/hr. Mr. [**Known lastname 39606**] worked with
PT/OT to get out of bed.
Throughout the day on, patient became increasingly weak in his
lower extremites, prompting repeat head CT and MRV, which showed
no hemorrhage or thrombosis. Subcutaneous heparin was started
in the evening to prevent against thrombosis. Out of concern
for focal seizures cause leg weakness, EEG was ordered.
On [**7-24**], the patient's blood pressure constraints were
liberalized to 120 < SBP < 160. Preliminary follow-up of EEG,
demonstrated slowing, frontal midline activity consistent with
edema. A neuro-oncology consult was placed with Dr. [**Last Name (STitle) **], who
recommended continuation of decadron at 6 mg q6h and zyprexia
for agiatation associated with steroids. DVT prophylaxis was
esclated to pneumoboots on the thighs and thigh-high tet hose.
As patient complained of consipation, his bowel regimen was
esclaated with magnesium citrate.
On [**7-25**], Mr. [**Known lastname 39606**] remained without seizures, EEG leads were
removed. Dermatology was consulted for a large new lip lesion
that developed post operatively. Cultures of the lesion were
sent as well as a small tissue sample. He was empiricly started
on Valtrex and symptomaticly treated with viscus lidocaine. A
doppler of the right side of his neck was ordered to rule out
intravascular clot in his IJ after IJ line removal.
On [**7-26**], patient's lower extremity weakness was mildly improved;
worse in distal>proximal lower extremities. Right IJ doppler
showed echogenic material consistent with wall trauma vs.
non-occlusive thrombus. No hematoma was seen.
On [**7-28**], a CT head was obtained which showed no evidence of
infarct or new hemorrhages. Now, DOD, he is afebrile, VSS, and
neuro stable. His incision is clean, dry and intact. His pain
is well-controlled and tolerating POs. He was evaluated by
PT/OT and they recommended acute rehab. He is set for discharge
and will follow-up accordingly.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Dexamethasone 2 mg PO Q6H
2. LeVETiracetam 1000 mg PO BID
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Dexamethasone 2 mg PO Q6H
2 tabs PO QID x 1 day
1 tab po QID x 1 day
1 tab po BID x 1 day then discontinue
2. LeVETiracetam 1000 mg PO BID
3. Acetaminophen 325-650 mg PO Q6H:PRN pain, T>38.5
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN headache
hold rr < 12
6. Insulin SC
Sliding Scale
Fingerstick QACHS, QPC2H, HS, QAM
Insulin SC Sliding Scale using REG Insulin
7. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
8. MethylPHENIDATE (Ritalin) 5 mg PO BID
9. OLANZapine 2.5 mg PO HS:PRN Anxiety
10. Senna 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 6689**] - [**Location (un) 6691**]
Discharge Diagnosis:
Porcine meningioma
Oral HSV
Lower extremity weakness
Cerebral Edema
Constipation
High blood pressure post-op
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:
Craniotomy for Tumor Excision
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? Your wound was closed with staples or non-dissolvable sutures
then 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) &
Senna 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 discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
??????You will an appointment in the Brain [**Hospital 341**] Clinic which will be
called to you. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**] if you do not receive a phone call or
please call if you need to change your appointment, or require
additional directions.
Completed by:[**2101-7-28**]
|
[
"300.00",
"564.00",
"796.2",
"225.2",
"348.5",
"E932.0",
"314.01",
"307.9",
"054.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
7592, 7666
|
3433, 6749
|
315, 437
|
7819, 7819
|
1904, 3410
|
9477, 9955
|
1202, 1220
|
6987, 7569
|
7687, 7798
|
6775, 6964
|
8002, 9454
|
1235, 1696
|
1712, 1885
|
266, 277
|
465, 1067
|
7834, 7978
|
1089, 1129
|
1145, 1186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,181
| 190,902
|
23126
|
Discharge summary
|
report
|
Admission Date: [**2196-2-14**] Discharge Date: [**2196-2-17**]
Date of Birth: [**2116-7-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Left upper abdominal pain and chest pain for 2 days. Transfer
from OSH.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 41447**] is a 79 year-old male with a past medical history
significant for HTN and ruptured AAA status post AAA repair 6
years ago, transferred from [**Hospital3 **] Hospital with a concern
over for possible type B aortic dissection.
He presented to the OSH on [**2196-2-13**] at night with a 2-day
history of left upper abdominal pain, initially low-grade, then
severe to 13/10 on the day of presentation, sharp,
non-radiating. He denies any associated N/V, no SOB, no
worsening LH or dizziness (per patient, he experiences chronic
LH and dizziness symptoms). No back pain. At the OSH, a CTPA was
negative for PE, but revealed a ? descending thoracic aortic
aneurysm. His SBP was in the 160s on presentation, and he was
given Labetalol 20 mg IV X 1 given, followed by Nitroprusside
drip started at 0.1 mcg/kg/min, titrated up for goal SBP<120. He
also received Toradol 30 mg IV, and Protonix 40 mg IV. He was
transferred to the [**Hospital1 18**] ED for further management.
In the [**Hospital1 18**] ED, initial vitals were T 98, HR 62, BP 116/74 on
Nipride, RR 11, Sat 96% on room air. He was seen by thoracic
surgery, who recommended medical management. He was admitted to
the CCU for further care.
Past Medical History:
History of ruptured AAA, status post AAA repair 6 years ago
Hypertension
Spinal stenosis, status post laminectomy C4-C5
Gastroesophageal reflux disease
History of CVA
Social History:
He admits to occasional EtOH. Active smoker, 60 pack-year
smoking history.
Family History:
Positive for CAD
Physical Exam:
Physical examination on admission to CCU.
VITALS: T 98, HR 56, regular, BP 94/45, RR 16, Sat 99% on 2L via
NC.
GEN: Pleasant, difficulty hearing. In NAD.
HEENT: Anicteric. MMM.
NECK: JVP flat. No carotid bruit.
RESP: Fair air entry bilaterally. Diffuse expiratory wheezes, no
crackles.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub.
GI: Midline abdominal scar. BS normoactive. Abdomen soft and
non-tender. No palpable pulsatile mass.
EXT: No femoral bruit. No pedal edema. Strong peipheral pulses.
NEURO: Alert and oriented.
Pertinent Results:
Pertinent laboratory data on admission:
CBC:
WBC-8.9 RBC-3.61* HGB-9.7* HCT-31.3* MCV-87 MCH-26.9* PLT
COUNT-223
NEUTS-66.3 LYMPHS-25.8 MONOS-4.2 EOS-2.9 BASOS-0.7
Chemistry:
GLUCOSE-111* UREA N-24* CREAT-0.9 SODIUM-141 POTASSIUM-4.1
CHLORIDE-105 TOTAL CO2-30* ANION GAP-10
Coagulation profile:
PT-12.7 PTT-27.8 INR(PT)-1.0
Cardiac enzymes:
CK(CPK)-42
CK-MB-NotDone cTropnT-<0.01
EKG: NSR, rate 64. Normal EKG.
Relevant data in hospital:
[**2196-2-15**] CT CHEST W/IV CONTRAST: Diffuse emphysematous changes
are noted throughout the lungs. No lung mass is identified. No
mediastinal or hilar lymphadenopathy.
CT ABDOMEN W/IV CONTRAST: The liver, adrenals, spleen, pancreas,
and kidneys are unremarkable. Simple cysts are noted within the
left kidney. No adenopathy.
CT PELVIS WITH IV CONTRAST: A Foley catheter is in place within
the urinary bladder. Prostatic calcifications are seen. The
colon appears unremarkable.
CT ARTERIOGRAM WITH IV CONTRAST, RECONSTRUCTIONS: The ascending
aorta demonstrates borderline enlargement, measuring 4 cm in
maximal axial dimension. Thoracic aorta measures 3.3 cm at the
isthmus, and 3.3 cm at the diaphragmatic hiatus. Thoracic aorta
is markedly tortuous. Within the distal descending thoracic
aorta, two areas of ulceration are identified measuring up to
approximately 7 mm. There is thickening of the posterolateral
aortic wall in the areas of penetrating ulcer, which are
thickened to approximately 1 cm. Unfortunately, since a
noncontrast CT scan of the chest was not performed prior to
contrast administration, acute hematoma vs. chronic thrombus
cannot be distinguished. However, given the relatively low
density of the aortic wall, thrombus is probably more likely. No
evidence of intimal flap within the thoracic aorta.
Abdominal aorta is normal in size, measuring up to 2.8 cm. The
celiac artery and superior mesenteric artery are widely patent.
The root of the inferior mesenteric artery is not opacified,
however, demonstrates contrast material shortly after its
origin. This may be related to relatively less contrast within
the anterior abdominal aorta at the level of the [**Female First Name (un) 899**] origin. A
surgical clip is also identified near the infrarenal abdominal
aorta on the right. Synthetic graft material is seen within the
distal aorta, extending into the origins of both common iliac
arteries. Shortly beyond the prosthetic graft limbs within the
common iliac arteries, there is aneurysmal dilatation of the
common iliac arteries. The right common iliac artery measures up
to 3.4 cm in maximal axial dimension, and the left common iliac
artery measures 2.8 cm. The internal and external iliac arteries
are patent, however, examination for subtle abnormalities within
these vessels is limited due to relatively poor opacification of
the distal abdominal aorta and iliac vessels.
No evidence of periaortic fluid or hematoma. A small amount of
wall thickening is seen within the distal abdominal aorta,
suggestive of thrombus.
The renal arteries are widely patent. Incidental note is made of
replaced left and right hepatic arteries.
BONE WINDOWS: No suspicious bony lesions. Degenerative changes
are seen within the thoracic and lumbar spine.
IMPRESSION:
1) Penetrating ulcers within the distal descending thoracic
aorta. Slight wall thickening within the distal thoracic aorta
may represent chronic thrombus, however, acute hematoma is less
likely. No intimal flap identified.
2) Post surgical changes within the abdominal aorta, with large
iliac artery aneurysms as described.
Brief Hospital Course:
79 year-old male with a history of HTN and AAA rupture s/p AAA
repair 6 years prior to admission, who presented to an OSH with
c/o abdominal pain, transferred to [**Hospital1 18**] given concern for
possible thoracic aortic dissection. His hospital course will be
reviewed by problems.
1) R/O aortic dissection: The OSH CT was reviewed on admission
with the radiology resident, with a differential diagnosis of
descending thoracic aortic dissection versus hematoma. CT
surgery was consulted and recommended medical management with
heart rate and blood pressure control. Mr. [**Known lastname 41447**] was admitted
to the CCU for close hemodynamic monitoring.
While in the CCU, he was continued on a Nipride drip for tight
blood pressure control, with goal SBP<120. A repeat CTA was
performed on [**2196-2-15**], which revealed penetrating ulcers within
the distal descending thoracic aorta, with slight wall
thickening felt to possibly represent a thrombus versus
hematoma, but without evidence of dissection. He remained pain
free in the CCU, and was transitioned to oral medications with
Metoprolol and Captopril, both titrated up to meet goal blood
pressure parameters. He remained stable throughout, with stable
hematocrit. Norvasc 5 mg PO QD was added on the day of discharge
for tighter blood pressure control.
Long-term risk factor management was also addressed. A lipid
profile revealed LDL 84. He was started on Lipitor 40 mg PO QD,
with goal LDL<70. He will need follow-up LFTs. Smoking cessation
counseling was also initiated, and will need to be readdressed
with Mr. [**Known lastname 41447**] as an out-patient.
He was discharged on Lisinopril 20 mg PO QD, Toprol 25 mg PO QD
and Norvasc 5 mg PO QD. He will need close BP monitoring as an
out-patient. He will also need a repeat CTA torso to assess
interval change in [**6-15**] weeks.
2) COPD: Mr. [**Known lastname 41447**] was noted to have significant wheezing on
admission. He was given bronchodilator therapy via nebulizers,
and started on Advair diskus, with significant improvement in
his respiratory status. A CT chest revealed no infiltrate, but
was significant for diffuse emphysematous changes. Emphasis was
placed on smoking cessation. He was discharged on Advair [**Hospital1 **],
Atrovent QID and Albuterol prn.
Medications on Admission:
Tramadol prn
Carbidopa/Levodopa 60 mg PO BID
Nexium
Ambien
Discharge Medications:
1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: [**1-10**]
inhalations Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Penetrating aortic ulcer
Hypertension
Chronic obstructive pulmonary disease
Discharge Condition:
Patient discharged home in stable condition.
Discharge Instructions:
You have a scheduled appointment with Dr. [**Last Name (STitle) **] on Friday
[**2-26**] at 15:30. It is important that you go to this
appointment.
We have also contact[**Name (NI) **] Dr.[**Name (NI) 59533**] office ([**Telephone/Fax (1) 59534**]).
They will contact you at home to schedule an appointment.
We have started new medications in the hospital. Please take all
medications as prescribed. Of note, we have also started
inhalers, which you should take daily even if no wheezing,
except for the albuterol, which you should only take as needed.
Most importantly, please stop smoking. You should also adhere to
a low sodium diet to help with blood pressure control.
Followup Instructions:
You have a scheduled appointment with Dr. [**Last Name (STitle) **] on Friday
[**2-26**] at 15:30. It is important that you go to this
appointment.
We have also contact[**Name (NI) **] Dr.[**Name (NI) 59533**] office ([**Telephone/Fax (1) 59534**]).
They will contact you at home to schedule an appointment.
Completed by:[**2196-2-18**]
|
[
"401.9",
"496",
"530.81",
"724.2",
"447.2",
"442.2",
"305.1",
"V12.59",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9700, 9706
|
6117, 8413
|
387, 393
|
9826, 9872
|
2531, 2557
|
10596, 10935
|
1946, 1964
|
8522, 9677
|
9727, 9805
|
8439, 8499
|
9896, 10573
|
1979, 2512
|
2875, 6094
|
276, 349
|
421, 1648
|
2571, 2858
|
1670, 1838
|
1854, 1930
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,780
| 152,873
|
5573+55683
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-4-7**] Discharge Date: [**2129-5-4**]
Date of Birth: [**2050-6-4**] Sex: M
Service: VSU
CHIEF COMPLAINT: Ischemic right lower extremity and foot
rest pain.
HISTORY OF PRESENT ILLNESS: This is a 78-year-old gentleman
who was recently discharged from [**Hospital1 190**] on [**2129-3-26**] after undergoing a right fem-
peroneal thrombectomy with patch angioplasty. Patient
underwent diagnostic arteriogram on that admission which
[**Year (4 digits) 3780**] right lower extremity occlusive disease with
high-grade stenosis at the proximal profunda and minimal
distal reconstruction. He returns now secondary to poor pain
control at home for possible intervention. He denies any
constitutional symptoms, chest pain, shortness of breath or
dyspnea. He denies any acute changes in his rest pain
symptoms, although he has noted increased erythema of the
lower extremity. He now is admitted for definitive treatment.
ALLERGIES: Morphine, oxycodone--manifestations not
documented.
PAST MEDICAL HISTORY: Hypertension, coronary artery disease
status post myocardial infarction in [**2128-3-16**], ejection
fraction is 35%, history of hypercholesterolemia, history of
chronic renal insufficiency, baseline creatinine 1.2, history
of peripheral vascular disease status post right external
iliac stenting status post left AKA, status post iliofemoral
endarterectomy on the left, status post right common femoral-
peroneal bypass with in situ saphenous vein in [**2120**], status
post right fem-peroneal with in situ saphenous vein to the
right fem-peroneal with thrombectomy and vein patch
angioplasty, right inguinal herniorrhaphy, status post
percutaneous transluminal coronary angioplasty with stenting
in [**2128-3-16**].
SOCIAL HISTORY: Significant for former smoking; he has not
smoked for 15 years. He denies alcohol use.
MEDICATIONS: Include Plavix 75 once daily, aspirin 81 mg
once daily, Norvasc 10 mg once daily, Proscar 5 mg once
daily, Lipitor 40 mg once daily, Paxil 40 mg once daily,
Colace 100 mg b.i.d., captopril 50 mg t.i.d., Lopressor 100
mg b.i.d., Neurontin 100 mg t.i.d., hydralazine 25 mg t.i.d.,
Flomax 0.8 mg at bedtime.
REVIEW OF SYSTEMS: Negative for syncope, dysarthria,
weakness, hemoptysis, diarrhea, hematochezia, melena,
dysuria, edema.
PHYSICAL EXAM: VITAL SIGNS: 98.6, 59, 18, blood pressure
110/20, O2 97% on room air. General appearance is alert,
oriented male in no acute distress. HEENT exam is
unremarkable. Carotids are palpable 1+ without bruits. There
is no lymphadenopathy. Lungs are clear to auscultation. Heart
is a regular rate and rhythm without murmur, gallop or rub.
Abdominal exam is benign. Lower extremity exam shows mild
blanching and erythema with tenderness to palpation. There is
no ecchymosis. Pulse exam shows carotids are palpable 1+.
Radials are Dopplerable signals bilaterally. Femoral on the
right is 2+ palpable, on the left Dopplerable signal. On the
right, the popliteal is Dopplerable. The pedal pulses are
absent. The patient has left AKA. Rectal exam - prostate is
firm, enlarged. Guaiac negative stool. Neurologic exam is
unremarkable.
HOSPITAL COURSE: The patient was admitted to the vascular
service. IV fluids were begun. Patient was started on
Dilaudid for analgesia control. A stool for C. diff was sent.
Routine labs, EKG and chest x-ray obtained. Acute pain
service was consulted, and recommendations to begin Dilaudid
PCA. They continued to follow the patient during his
hospitalization until his initial surgery with adjustment in
his PCA dosing for adequate pain control. The patient was
continued on IV heparin with some improvement in his ischemic
pain. Foley was placed for urinary retention. Patient
proceeded to surgery on [**2129-4-12**] and underwent a right
common femoral-profunda bypass with ringed [**Doctor Last Name 4726**]-Tex graft.
The patient tolerated the procedure well and was extubated in
the OR and transferred to the PACU in stable condition.
Postoperatively, the patient remained stable and was
transferred to the VICU for continued monitoring and care.
His postoperative hematocrit was 25.8. He was started on
perioperative vancomycin. He was transfused for his
hematocrit. Postoperative day 2, his Dilaudid IV was
discontinued, and he was begun on tramadol 1-2 tablets q. 4
h. p.r.n. for pain with Tylenol 650 mg q. 6 h. around-the-
clock, and Neurontin was increased to 200 t.i.d. Dilaudid was
recommended only if tramadol did not provide adequate pain
control. Physical therapy saw the patient on [**2129-4-13**]
and recommended rehab therapy. Postoperative day 2, he
continued on his IV heparin. His foot looked dusky. PVRs were
obtained which showed extremely poor perfusion at all levels.
Heparinization was continued. Coumadinization was instituted.
He remained in the VICU.
Patient was transferred to the regular nursing floor on [**2129-4-14**]. The Foley was removed, but the patient failed to
void, and Foley was replaced on [**2129-4-17**]. Physical
therapy continued to work with the patient. On [**4-22**],
patient was prepared for surgery, after discussing with both
the patient and the family that he would require above-knee
amputation. His INR was 2.3 and required fresh frozen plasma
for reversal. He was also transfused for hematocrit of 24.3.
Post-transfusion crit was 28.4. Patient underwent a right
above-knee amputation on [**2129-4-22**]. He developed
postoperative hypotension with a rise in his troponin. EKG
was without any significant changes. The patient was
transferred to the SICU for continued monitoring and
vasopressive support. Patient was in congestive failure. IV
Lasix was begun. IV heparinization was instituted secondary
to evidence of MI by troponin levels. The patient was
intubated the following day because of hypoxia. Patient
remained intubated and underwent a diagnostic cardiac cath on
[**2129-4-25**] via the right brachial artery which
[**Year (4 digits) 3780**] main trunk stent was patent, the left anterior
descending with diffuse disease with a stenosis of 50%, the
left circumflex was totally occluded to the first obtuse
marginal, the right coronary artery was the dominant system
with an 80% stenosis in the PDA.
The patient continued to remain intubated. Tube feeds were
started on [**4-25**]. Patient developed rapid atrial
fibrillation on [**4-27**] which required amiodarone drip and
continued amiodarone conversion to oral medication. IV
heparinization was continued. On [**4-28**], the patient
continued in significant congestive heart failure requiring
continued IV Lasix. We could not wean the patient from the
vent. It was discussed with the patient's family, and the
patient was made DNR/DNI. Patient was then extubated. On
[**4-29**], he was transferred to the VICU for continued
monitoring and care. On [**5-1**], the patient remained in the
VICU. A-line was discontinued. Patient was made floor status
with telemetry. Patient continued on his tube feeds and oral
feedings. Rehab screening was begun. Patient will be
discharged when medically stable to rehab.
DISCHARGE MEDICATIONS: Include Finasteride 5 mg daily,
paroxetine 40 mg daily, Tamsulosin 0.4 mg capsules daily,
bisacodyl suppositories once daily p.r.n., hydromorphone 0.5
mg IM q. 6 h. as needed, pentamidine 20 mg b.i.d., magnesium
hydroxide 400 mg in 5 cc 30 cc q. 6 h. p.r.n., tramadol 50 mg
q. [**4-21**] h. p.r.n., gabapentin 200 mg t.i.d., Colace 100 mg
b.i.d., atorvastatin 40 mg once daily, aspirin 81 mg once
daily, Plavix 75 mg once daily, acetaminophen 325 mg [**1-17**] q. 4
h., amiodarone 800 mg daily for a total of 6 days which was
started on [**2129-4-29**]. That should continue until [**2129-5-5**]. On [**2129-5-6**], Amiodarone 400 mg daily will be
started for a total of 3 weeks, lorazepam 0.5-1 mg IV q. 6 h.
p.r.n., Lopressor 50 mg t.i.d., hydralazine 50 mg q. 6 h.,
lisinopril 5 mg once daily.
DISCHARGE INSTRUCTIONS: Patient should follow-up with Dr.
[**Last Name (STitle) **] in 4 weeks time from the date of discharge. Skin
clips remain in place until seen in follow-up. No stump
shrinkers on the amputation site. Dry sterile dressings
daily, as long as wounds are draining, then thereafter may be
open to air.
DISCHARGE DIAGNOSES: Right foot ischemic, rest pain,
peripheral vascular disease status post right external iliac
stenting, status post left above-knee amputation, status post
left iliofemoral endarterectomy, status post right common
femoral-peroneal bypass with in situ saphenous vein, status
post right femoral-peroneal thrombectomy with vein
angioplasty, history of hypertension, history of coronary
artery disease, history of myocardial infarction status post
percutaneous transluminal coronary angioplasties with
stenting [**2128-3-16**], history of hypercholesterolemia, history
of right inguinal hernia status post repair, postoperative
urinary retention, postoperative blood loss anemia--
transfused, postoperative non-ST elevation myocardial
infarction on [**2129-4-23**], postoperative congestive heart
failure secondary to myocardial infarction, postoperative
hypertension--uncontrolled, requiring medication adjustment,
Vancomycin-resistant Enterococci by rectal swab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2129-5-2**] 09:31:40
T: [**2129-5-2**] 10:15:08
Job#: [**Job Number 22427**]
Name: [**Known lastname 3749**],[**Known firstname **] Unit No: [**Numeric Identifier 3750**]
Admission Date: [**2129-4-7**] Discharge Date: [**2129-5-6**]
Date of Birth: [**2050-6-4**] Sex: M
Service: SURGERY
Allergies:
Morphine / Oxycodone
Attending:[**First Name3 (LF) 1546**]
Addendum:
Completion of hospital course:
- On [**5-2**] the pt. was transferred to floor status and
continued to do well. He remained afebrile with stable vitals,
pain was well controlled, and incisions were clean, dry, and
intact. For the next four days the pt. continued to be stable,
rehab screening was undertaken, he was seen by the wound care
service for his coccyx ulcer, and was prepping for discharge.
His PO intake was good while having help from the nursing staff
to eat and he was maintained on his SSRI. The pt. was also
started on dietary supplements - boost and mighty shakes - to
improve his nutritional status. On [**5-3**] the staples from
his right groin (the RCFA to profunda bypass site) were removed
and steri strips placed. On [**5-5**] a bed became available at
rehab and the pt. was transferred out. He was sent with
instructions regarding follow-up appointments with Dr.
[**Last Name (STitle) **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2129-5-5**]
|
[
"V49.76",
"414.8",
"707.03",
"401.9",
"440.24",
"V58.67",
"427.31",
"788.20",
"V58.61",
"250.00",
"518.82",
"414.01",
"280.0",
"410.71",
"428.0",
"458.29",
"440.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.17",
"37.22",
"99.07",
"88.55",
"96.04",
"96.6",
"96.71",
"39.49",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10773, 10981
|
8252, 9843
|
7110, 7908
|
9860, 10750
|
7933, 8230
|
2332, 3154
|
2211, 2316
|
151, 203
|
232, 1024
|
1047, 1766
|
1783, 2191
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,454
| 189,976
|
45762
|
Discharge summary
|
report
|
Admission Date: [**2104-2-11**] Discharge Date: [**2104-2-14**]
Date of Birth: [**2041-9-26**] Sex: F
Service: MEDICINE
Allergies:
Ceclor / Antihistamines / Penicillins / Kiwi (Actinidia
Chinensis) / Egg / multiple Antibiotics / IV Dye, Iodine
Containing / morphine / Tylenol / Cipro / Levofloxacin / Bactrim
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
diverticulitis
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE
Date: [**2104-2-13**]
Time: 23:55
The patient is a 62 yo F with numerous drug allergies, HTN,
asthma, migraines, fibromyalgia, h/o recurrent diverticulitis
who presents with fever, nausea, vomiting, LLQ pain, dysuria,
and intermittent diarrhea/constipation. She began to have
abdominal pain 4 days prior to admission. She then developed low
grade fever and chills with temperature at home 99-100.1 F
(baseline temp 97 per patient). Her abdominal pain began as
suprapubic pain and she endorsed bladder discomfort on urination
but no dysuria. She went to see her gastroenterologist who
referred her to the ED for further evaluation. She had a CT scan
that showed evidence of diverticulitis. She was made NPO and
placed on IVF. She refused antibiotics on the floor given her
history of allergies to multiple antibiotics. She require
antibiotic treatment with amoxicillin-clavulanate acid due to a
possible gastrointestinal microperforation.
The patient was seen by [**First Name8 (NamePattern2) 2602**] [**Doctor Last Name 2603**] from allergy (her
outpatient allergist is Dr [**Last Name (STitle) **], a [**Hospital1 756**] allergy), who
made specific recommendations for Augmentin desensitization. Of
note, patient has undergone augmentin desensitization in the
past without issue. She was transferred to the [**Hospital Unit Name 153**] for the
antibiotic desensitization protocol, which she tollerated well.
She is being transferred back to the medicine floor for further
management.
Just prior to transfer from the [**Hospital Unit Name 153**] to the medicine floor, she
reports feeling a bit tired, but is comfortable. She endorses
her usual wheezing from asthma. She denies chest pain, rash or
abdominal pain.
Review of systems:
(+) Per HPI, also night sweats, chronic migraine headache (but
none currently), endorses dry cough and mild SOB/ wheezing she
relates to her asthma. Occasional palpitations. Has alternating
diarrhea/ constipation. +mylagias related to fibromylgia, mild
rash under left breast.
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denies chest pain, chest pressure.
Denies vomiting.
Past Medical History:
PMH:
-allergic rhinitis
-asthma
-migraine headaches
-fibromyalgia
-hypertension
-gastroesophageal reflux disease,
-hypercholesterolemia
-stress urinary incontinence
-2 prior episodes of diverticulitis
PSH:
-removal left adnexal cyst [**2103-6-8**]
-open gastric bypass approximately 30 years ago
Social History:
Married with two adult sons. She works as a adolescent
psychologist. She does not drink alcohol, smoke or use illicit
drugs.
Family History:
Youngest son with asthma. [**Name (NI) **] father has multiple food
allergies.
Physical Exam:
VS: 97.6 189/70 67 18 97%RA, 0/10 pain
GEN: No apparent distress
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Mild expiratory wheeze on right > left, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended, no guarding/rebound; obese
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**4-12**] motor function globally
DERM: no lesions appreciated
Discharge Exam
VSS
GEN: Patient lying comfortably in bed nad a+ox3
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
DERM: no rashes, ulcers or petechiae
neuro: cn 2-12 grossly intact non-focal
PSYCH: normal affect and mood
Pertinent Results:
ADMISSION LABS:
[**2104-2-11**] 03:40PM BLOOD WBC-8.3 RBC-4.17* Hgb-12.9 Hct-36.2
MCV-87 MCH-31.1 MCHC-35.8* RDW-12.6 Plt Ct-292
[**2104-2-11**] 03:40PM BLOOD Neuts-66.6 Lymphs-25.0 Monos-5.3 Eos-2.7
Baso-0.4
[**2104-2-11**] 03:40PM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-140
K-3.6 Cl-102 HCO3-28 AnGap-14
[**2104-2-11**] 03:40PM BLOOD ALT-29 AST-20 AlkPhos-64 TotBili-1.5
[**2104-2-12**] 05:12AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
[**2104-2-11**] 03:40PM BLOOD Albumin-4.2
[**2104-2-11**] 10:29PM BLOOD Lactate-1.3
DISCHARGE LABS:
[**2104-2-14**] 05:00AM BLOOD WBC-6.9 RBC-3.90* Hgb-12.3 Hct-34.3*
MCV-88 MCH-31.4 MCHC-35.7* RDW-12.4 Plt Ct-339
[**2104-2-14**] 05:00AM BLOOD Glucose-88 UreaN-6 Creat-0.5 Na-140 K-3.7
Cl-102 HCO3-28 AnGap-14
MICROBIOLOGIC DATA:
[**2104-2-11**] Blood culture (x 2) - No growth to date
IMAGING STUDIES:
[**2104-2-11**] CT ABD & PELVIS W/O CON - Sigmoid diverticulitis. Focus
of gas along the colon in this region likely represents
diverticulum, although a microperforation is difficult to
exclude, but felt unlikely. No drainable fluid collection.
Gastrogastric fistula again seen in this patient status post
gastric bypass. Hepatic steatosis.
Brief Hospital Course:
Assessment and Plan:
62F with a h/o multiple antibiotic allergies, who presented with
her third epsidode of recurrent diverticulitis with possible
colonic microperforation, now s/p augmentin desensitization and
being transferred back to the medicine floor.
# DIVERTICULITIS - The patient presented with left lower
quadrant pain and low grade fevers, with evidence of
diverticulitis of the sigmoid colon on CT imaging. She required
Augmentin treatment and completed a course following
desensitization noted above. She was maintained NPO above, given
IV fluids and Dilaudid for pain control. Colorectal surgery
followed the patient and agreed with antibiotics and noted she
had no acute surgical needs. After amoxicillin
desensitization(see below) she was continued on augmentin and
was able to tolerate po. No fevers or leukocytosis on day of
discharge. Patient discharged on augmentin to complete a 14 day
course and atarax for prn for rash. She will follow up with her
pcp..
# AMOXICILLIN DESENSITIZATION - Patient has a history of
multiple allergies to medications with reactions that have
included swelling, pruritis and generalized rash. She presented
with an episode of diverticulitis requiring antibiotic therapy,
and thus she was transferred to the ICU for antibiotic
desensitization. With the assistance of the Allergy specialist,
she was dosed step-wise with Augmentin over several hours with
no allergic response and she tolerated the final dose well. Once
she completed the full dosing she was monitored for 1-hour in
the ICU and transferred back to the Medicine floor. Epinephrine
and steroids were made available but were not required.
.
# ASTHMA - continued on home albuterol and fluticasone inhalers
.
# HYPERTENSION - continue lisinopril on discharge
.
# HYPERLIPIDEMIA - We continued her home dosing of Zocor 40 mg
PO daily (patient unable to tolerate generic Simvastatin).
Medications on Admission:
-albuterol 90 mcg 2 puffs prn SOB/ wheezing (uses ~2x/day)
-Flovent 2 puffs [**Hospital1 **]
-Zestril 20 mg po daily
-Zocor 40 mg po daily
-vitamin D3
-calcium
-multivitamin
-Zantac 150 mg po BID
-vitamin E
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
2. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Zestril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
6. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 13 days: Take [**12-10**] tab po, then
wait 20-30 minutes and take [**12-10**] tab. .
Disp:*39 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and found to have
diverticulitis. Because of your previous allergies to
antibiotics, an antibiotic desensitization protocol was used and
you were started on Augmentin. On the day of discharge you were
tolerating oral intake. Please continue taking Augmentin for a
total of 14 days and follow up with your primary care physician
New medication
1. Augmentin for 14 day course
Followup Instructions:
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 97509**],MD
Specialty: Primary Care
Location: [**Location (un) 4499**] INTERNAL MEDICINE
Address: [**Apartment Address(1) 97508**], [**Location (un) 4499**],[**Numeric Identifier 4501**]
Phone: [**0-0-**]
When: Tuesday, [**2-19**] at 4:00pm
|
[
"530.81",
"346.90",
"V14.1",
"562.11",
"401.9",
"625.6",
"729.1",
"V45.86",
"272.0",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8251, 8257
|
5438, 7338
|
453, 480
|
8315, 8315
|
4232, 4232
|
8905, 9218
|
3194, 3275
|
7596, 8228
|
8278, 8294
|
7364, 7573
|
8465, 8882
|
4766, 5054
|
3290, 4213
|
2294, 2715
|
398, 415
|
508, 2275
|
4249, 4750
|
8330, 8441
|
2737, 3035
|
3051, 3178
|
5072, 5415
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,411
| 129,942
|
35329
|
Discharge summary
|
report
|
Admission Date: [**2158-4-21**] Discharge Date: [**2158-5-11**]
Date of Birth: [**2098-2-25**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Metastatic breast cancer to the liver and right adrenal gland.
Major Surgical or Invasive Procedure:
Right hepatic trisegmentectomy, cholecystectomy, right
adrenalectomy, intraoperative ultrasound, Roux-en-Y
hepaticojejunostomy to the left lateral segment duct,
radiofrequency ablation of the left lateral segment tumors x4.
History of Present Illness:
Per Dr [**Last Name (STitle) 4727**] note:60-year- old female who underwent a right
partial mastectomy in [**8-21**] for a 3 x 2.3 cm grade 3 infiltrating
ductal carcinoma,
ER negative, ER 1%, HER-2/neu positive by FISH. Sentinel lymph
nodes were negative. She underwent adjuvant chemotherapy
beginning in [**2155-10-17**] with four cycles of AC followed by
12 weeks of combination Taxol and Herceptin started in [**12-22**]
(completed [**2-22**]) She completed a full year of Herceptin in
[**12-23**]. She underwent a bilateral prophylactic mastectomy in
[**4-22**] with
bilateral reconstruction. Due to abdominal discomfort, she
recently underwent a RUQ ultrasound which showed multiple solid
lesions in the liver, the largest being 14 cm. Chest CT in [**2-24**]
demonstrated no evidence of lung metastases. A CT of the
abdomen and pelvis demonstrated a cavernous hemangioma in the
left lateral segment which was unchanged and had been seen
before. There were now new multiple peripheral enhancing/central
nonenhancing lesions throughout much of the right lobe of the
liver, largest measuring 10 cm in size.
There was also a mass within the right adrenal gland that had
increased in size and now measured 3.2 cm suspicious for
metastatic disease.
MRI of the brain was negative. A bone scan demonstrated no
evidence for osseous metastatic disease. Cardiac echo was
normal.
Needle biopsy of the liver demonstrated poorly-differentiated
carcinoma consistent with a breast carcinoma.
Following referral to [**Hospital1 18**], triphasic CT confirmed disease in
the right lobe of the liver as well as medial segment and
caudate lobe. There were also two to three lesions in the left
lateral segment.
In preparation for surgery, she underwent preoperative right
portal vein embolization and is admitted for surgical resection
with Dr [**Last Name (STitle) **].
Past Medical History:
Breast CA: Right partial mastectomy, Taxol and Herceptin Chemo
then bilatreal prophylactic mastectomy with reconstruction,
starting in [**2155**].
Agaraphobia, bunionectomy requiring foot reconstruction in [**2152**],
appendectomy in [**2108**], D&C post miscarriage in [**2122**]
.
Social History:
Married with 2 children. Occasional alcoholic beverage,
30 year smoking history 1 pack per day; continues to smoke. NO
IVDU or tattoos. Has a nose piercing.
Family History:
mother died age [**Age over 90 **] of stomach cancer but also had
a history of colon cancer.
Father died at age 73 of congestive heart failure.
Maternal grandfather died at 77 of cancer. Maternal grandmother
died at 67 of ICB. Paternal grandfather died in his 60s in a
motor vehicle accident. Paternal grandmother died of unknown
causes. She has two brothers and sisters who are healthy.
Physical Exam:
VS: 98.2, 91, 104/71, 18, 100%
Gen: NAD
Lungs: Clear
Card: RRR
Abd: Soft, tender to palpation, non-distended, JP x2, and
biliary drain
Extr: No edema
Pertinent Results:
On Admission: [**2158-4-21**]
WBC-9.9 RBC-3.40* Hgb-11.1* Hct-32.9* MCV-97 MCH-32.5* MCHC-33.7
RDW-15.2 Plt Ct-215
PT-17.1* PTT-39.4* INR(PT)-1.5*
Glucose-109* UreaN-16 Creat-1.2* Na-144 K-5.4* Cl-116* HCO3-24
AnGap-9
ALT-667* AST-921* AlkPhos-69 TotBili-2.7*
Albumin-2.2* Calcium-7.4* Phos-5.5*# Mg-1.7
On Discharge: [**2158-5-11**]
WBC-7.3 RBC-2.62* Hgb-9.6* Hct-28.6* MCV-109* MCH-36.6*
MCHC-33.5 RDW-19.8* Plt Ct-266
Glucose-85 UreaN-6 Creat-0.7 Na-131* K-3.7 Cl-101 HCO3-24
AnGap-10
ALT-97* AST-120* AlkPhos-97 TotBili-17.1* Albumin-2.2*
Calcium-7.7* Phos-3.1 Mg-2.2
Brief Hospital Course:
Patient was admitted to Dr.[**Name (NI) 1369**] surgical service and taken
to the operating room on [**2158-4-21**] for right hepatic
trisegmentectomy, cholecystectomy, right adrenalectomy,
intraoperative ultrasound, Roux-en-Y hepaticojejunostomy to the
left lateral segment duct, radiofrequency ablation of the left
lateral segment tumors x4 for metastatic breast cancer to the
liver and right adrenal gland.
Per the operative report, intraoperative ultrasound demonstrated
the lesions in the medial segment and right lobe of the liver.
There were also four suspicious lesions in the left lateral
segment and all of these were successfully ablated using
radiofrequency ablation. The adrenal gland was enlarged and was
removed en bloc with the liver. She had normal portal anatomy.
The left lateral segment was markedly enlarged.
Please see the operative note for surgical detail.
In the post op period she was having low urine outputs and
receiving bolus fluids. In addition she was treated for a K of
5.9.
An ultrasound of the liver was obtained which showed the left
portal vein with normal flow and waveform. The main and left
hepatic artery also demonstrated normal flow and waveform, as
does the IVC and left hepatic vein.
Due to anxiety she was restarted on her home dose of Xanax. In
addition she was receiving morphine for pain control. Her mental
status became worse and she was very sedated. Repeat ultrasound
indicated no flow problems to the liver. Ct of the abdomen was
unremarkable, not showing any fluid collections and having
normal post surgical/ablation changes. She was transferred to
the SICU after receiving flumenazil with little effect on mental
status. Hepatology was consulted who suggested the initiation of
lactulose, avoiding narcotics as much as possible and
anxiolytics altogether. A head CT did not show any acute
abnormality. By EEG she was showing either a metabolic
derangment or encephalopathy. She was started on lactulose with
excellent response.
She became less sedated, continued with confusion which waned
and was resolved by POD 7. During this time she was started on
Rifaxamin which she will continue as an outpatient.
AST and ALT were at their maximum on POD 1 and 2 and trended
down but not normalized by day of discharge. The alk phos
remianed stable throughout. The Total bili continued to climb
throughout the hospitalization with maximum value of 19.6 on POD
21.
She was tolerating a regular diet at discharge and calorie
counts revealed an average caloric intake around 1700 calories.
She has been using supplements in addition to her regular diet.
Dr [**Last Name (STitle) **] came by while she was inpatient and talked with
[**Known firstname **] regarding when the Herceptin might be restarted and will
see her as an outpatient to plan her future chemo course.
She improved with ambulation and was deemed safe to d/c home
without physical therapy.
A psychiatry consult was called due to patients' increasing
anxiety. We were resistant to restarting any benzodiazepines.
She stated she would be fine once home, and meeting with the
oncologist helped calm some of her anxiety and concerns. She was
counseled by this writer to not initiate her home xanax due to
continued decreased liver function, the patient stated
understanding.
The Roux tube was capped on POD 19 following a cholangiogram
demonstrating no evidence of leak. The bilirubin took a small
jump but did not return to its former elevated value of 19. The
medial drain was removed leaving her with the lateral drain and
capped Roux tube for home which she was quite comfortable with
the care of.
She is being discharged on Rifaxamin. No benzos or pain meds
were ordered for home.
Medications on Admission:
Xanax PRN
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Outpatient Lab Work
PLease draw AST, ALT, Alk Phos, T Bili
Fax results to Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 697**]
Labs to be drawn Friday [**5-12**] and Monday [**5-15**]
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast cancer to the liver and right adrenal gland.
Discharge Condition:
Good
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarrhea, constipation, increased yellowing of
the eyes, abdominal pain or any other concerning symptoms
Avoid heavy lifting
You may shower, avoid tub baths. Place drain sponge around the
drain site daily and as needed. Always pin up bag, do not allow
them to hang freely.
Coil Roux tube drain under dressing daily. Keep tube from
getting snagged on clothing
Avoid the use of Xanax for now as this may cause increased
confusion
Drain and record JP bulb drainage twice daily and as needed.
Bring a copy of the record with you to your clinic visit. Report
any large changes in the volume or if the drainage appears
bloody or develops a foul odor.
Labwork to be drawn at [**Hospital **] Hospital Friday [**5-12**] and Monday
[**5-15**]. Have results faxed to [**Telephone/Fax (1) 697**]
Followup Instructions:
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; [**Telephone/Fax (1) 673**], Wednesday [**5-17**] @ 3:00 pm
Follow up with Dr [**Last Name (STitle) 80555**]; [**0-0-**]. Call for appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2158-5-11**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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8250, 8256
|
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|
8363, 8370
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3572, 3572
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2992, 3386
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3401, 3553
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3586, 3876
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,448
| 175,143
|
45774
|
Discharge summary
|
report
|
Admission Date: [**2125-1-2**] Discharge Date: [**2125-1-8**]
Date of Birth: [**2069-5-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 14879**] is a 55 year old gentleman who was found sleeping
outside by the police and brought into the ED. His initial
complaints were back pain and progressive dyspnea. He reports
last drink was approximately 1-2 days prior from admission. He
denies any falls or other recent trauma.
.
In the ED, initial VS: 120 164/99 20 85% RA. He was cold to the
touch and shivering with wet clothing and also tremulous. He
complained of nausea and vomited once approximately 200mL of red
bloody vomitus. NG lavage returned another 100mL of bloody fluid
that cleared with an additional 200mL. Guaiac Negative.
Hepatology was initially consulted as he is followed there. The
patient was given Zofran, Ativan 6mg IV total(for nausea and
withdrawal) and protonix, 3L IV fluid including 1 banana bag. K
2.9, started on 40 PO Potassium, 40mEq IV. Transfer VS: 99.8 132
116/73 25 94% RA, never hypotensive, persistently tachycardic.
.
Currently, the patient is comfortable on arrival to the ICU. He
reports that his back pain is chronic lower back pain, and
continues to deny any falls or trauma. He denies chest pain, but
reports baseline worsening progressive dyspnea. He denies
abdominal pain or nausea at this time. He reports that his
bloody emesis was his only recent episode of vomiting. He denies
black or bloody stools, lightheadedness or dizziness.
.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Atrial fibrillation
Tachycardia induce cardiomyopathy; resolved
Alcohol abuse
Hypertension
2.5-cm cystic lesion in pancreatic tail ([**2121**])
Colonic polyposis
Status post knee replacement
Hepatitis B & C/ETOH grade 3 fibrosis.
Back arthritis
C.diff colitis
Social History:
Currently homeless, sleeps "where you return your bottles and
boxes for recycling." He drinks ~ 1 quart of alcohol including
listerine daily. Smokes 2 packs daily.
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
Admission Exam:
Vitals - T: 100.1 BP: 154/85 HR: 127 RR: 17 02 sat: 98% RA
GENERAL: Non-toxic appearance, breathing comfortably
HEENT: No LAD, Dry mucous membranes
CARDIAC: S1 & S2 fast without murmur
LUNG: B CTA, cough on deep inspriation x1
ABDOMEN: nontender, nondistended. BS present
BACK: Tender to palpation in lumbar spine, no ulcers
EXT: 2+ DP, contracted/stiff limbs, no edema
NEURO:
MS: AAOx3, answers most questions appropriately but some
inappropriately responses
CN: II-XII grossly intact
Strength: [**3-21**] all extremities, equal
+ Bilateral lower extremity clonus
DERM: weathered skin, no obvious lesions
Pertinent Results:
Admission Labs:
[**2125-1-2**] 01:00PM WBC-9.0# RBC-3.88*# HGB-12.8*# HCT-36.4*
MCV-94# MCH-33.1* MCHC-35.2*# RDW-15.0
[**2125-1-2**] 01:00PM CALCIUM-8.2* PHOSPHATE-4.0 MAGNESIUM-1.9
[**2125-1-2**] 01:00PM LIPASE-30
[**2125-1-2**] 01:00PM ALT(SGPT)-95* AST(SGOT)-281* ALK PHOS-105 TOT
BILI-0.8
[**2125-1-2**] 01:00PM GLUCOSE-65* UREA N-28* CREAT-0.9 SODIUM-139
POTASSIUM-2.7* CHLORIDE-86* TOTAL CO2-19* ANION GAP-37*
[**2125-1-2**] 01:14PM LACTATE-4.2*
[**2125-1-2**] 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2125-1-2**] 01:00PM URINE HOURS-RANDOM
[**2125-1-2**] 01:00PM ASA-5 ETHANOL-155* ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-N
[**2125-1-8**] 06:15PM BLOOD WBC-5.2 RBC-3.26* Hgb-10.5* Hct-31.8*
MCV-97 MCH-32.2* MCHC-33.1 RDW-14.9 Plt Ct-237
[**2125-1-8**] 07:15AM BLOOD PT-12.6 PTT-26.8 INR(PT)-1.1
[**2125-1-8**] 07:15AM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-135
K-3.8 Cl-106 HCO3-22 AnGap-11
[**2125-1-5**] 07:10AM BLOOD ALT-96* AST-295* AlkPhos-90 TotBili-0.8
[**2125-1-8**] 07:15AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.6
[**2125-1-4**] 07:55PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2125-1-2**] 09:41PM BLOOD TSH-1.1
[**2125-1-2**] 09:41PM BLOOD Osmolal-305
[**2125-1-3**] 11:08AM BLOOD calTIBC-152* Ferritn-779* TRF-117*
[**2125-1-4**] 07:55PM BLOOD IgG-1352 IgM-398*
[**2125-1-2**] 01:00PM BLOOD ASA-5 Ethanol-155* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2125-1-6**] Cardiology ECG: Sinus tachycardia. Occasional
premature atrial contractions. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2125-1-2**] no change.
[**2125-1-4**] Radiology ABDOMEN U.S. (COMPLETE): IMPRESSION:
Echogenic liver consistent with fatty infiltration. However,
other forms of liver disease and more advanced liver disease
(i.e., significant hepatic fibrosis/cirrhosis) cannot be
excluded. No concerning focal hepatic lesions.
[**2125-1-3**] Radiology CHEST (PORTABLE AP): There is again a left
lower lobe consolidation demonstrated, that appears to be
slightly progressed since the prior study and might be
consistent with worsening infectious process. Cardiomediastinal
silhouette is stable.
[**2125-1-2**] Radiology CHEST (PORTABLE AP): IMPRESSION: Limited
study as the entire left chest is not seen on this film. Left
lower lobe opacity, non-specific, possibly representing
atelectasis or pneumonia.
[**2125-1-2**] Cardiology ECG: Sinus tachycardia. Indeterminate
axis. Low limb lead QRS voltage. Findings are non-specific.
Otherwise, baseline artifact makes assessment difficult. Since
the previous tracing of [**2124-6-1**] sinus tachycardia is now present
but, otherwise, baseline artifact makes assessment difficult.
[**2125-1-6**] URINE CULTURE - NEG
[**2125-1-5**] BLOOD CULTURE - PENDING
[**2125-1-5**] BLOOD CULTURE - PENDING
[**2125-1-5**] C. Diff - NEG
[**2125-1-4**] C. Diff - NEG
[**2125-1-4**] URINE URINE -PENDING
[**2125-1-3**] BLOOD CULTURE -PENDING
[**2125-1-3**] BLOOD CULTURE -PENDING
[**2125-1-2**] URINE URINE - NEG
[**2125-1-2**] MRSA SCREEN - NEG
[**2125-1-2**] BLOOD CULTURE - NEG
[**2125-1-2**] BLOOD CULTURE - NEG
Brief Hospital Course:
ASSESSMENT & PLAN:
A 55-year-old homeless gentleman admitted to the MICU for upper
GI bleed and alcohol withdrawal. He is not acting as though he
is having a major GI bleed as the cause of his symptoms, nor is
there any clear source of infection or underlying pathology to
explain why he would withdraw at this time. He is comfortable at
the time of admission.
.
#. Hematemesis: The patient had one episode of
nausea/hematemesis after receiving PO Potasssium. He denied any
nausea or vomiting and was guaiac negative. Last EGD [**2119**] with
no varices but does have known liver disease. No evidence of
ongoing bleeding, abdominal pain, etc. Possible etiologies
include variceal bleed, ulcer disease or [**Doctor First Name **]-[**Doctor Last Name **] tear (if
he has vomited in the past few days). He was given Protonix IV
BID. Serial Hct were stable. Liver was consulted and agreed to
do endoscopy non-urgently; however, given patient was
hemodynamically unstable due to withdraw (tachycardia, agitated,
tachypnic)- this was deferred to an outpatient process. Patient
was discharged with these appointments and instructions.
.
#. Tachycardia: Initially sinus tachy to the 110s-130s, likely
secondary to fever, EtOH withdrawal, and fluid depletion. His
BP was consistently normal to high. Home anti-hypertensive
(atenolol) was changed to half the equivalent dose of
metoprolol. This was additionally titrated up prior to
discharge. His heart rate came down appropriately.
.
# Fever and infiltrate: CXR and CT indicated LLL pneumonia,
likely secondary to aspiration. Ceftriaxone and azithromycin
were started for CAP, he continued to spike. Antibiotics were
swtiched to levofloxacin and flagyl. Fever resolved and he
improved clinically at time of discharge.
.
#. Elevated transaminases: History of Hep B/C. LFTs elevated
somewhat above previous values on admission. Liver followed and
will continue to as outpatient.
#. Alcohol withdrawal: Patient, tachycardic, tremulous,
anxious. No history of withdrawal seizures per patient. He was
initially given diazepam IV per CIWA, then converted to PO.
Thiamine, folate, MVI were started.
#. Elevated Anion Gap: Patient's anion Gap 34. Given a lactate
of 4 reducing with fluids, this likely represented alcoholic and
starvation ketoacidosis. Gap closed after hydration.
#. Abnormal U/A: + Hematuria possibly myoglobin from muscle
damage as 0 RBCs on sediment. Urine culture was negative.
#. Paroxysmal Atrial fibrillation: Currently in sinus, will hold
anticoagulation given bleed. He was placed on his home
medications at the time of discharge.
#. H/o hypertension: Will permit him to be mildly hypertensive
as he is now, will control hypertension via withdrawal as above
and address any urgency without beta blockade given GI bleed.
# CODE: Full
# Discharge: Patient demanded to leave multiple times during his
stay. He initially refused EGD and all testing. Psychiatry was
called to evaluate patients ability to make decisions. He
voiced appropriate understanding of the pros and cons of having
the procedure and that he understood the reasons of why we want
he to get the test (please refer to omr for full note). He
contiued to be belligerant and threatening to his medical team.
On the day of discharge, he demanded to be leave the hospital
with or without the approval of his medical team. Since he does
appear to have full appreciation of his medical issues and
understand the importance to follow up with outpatient doctors.
He was seen by social work and physical therapy, who cleared him
to go. He was discharged in stable condition with new
prescriptions to all his medications.
Medications on Admission:
Aspirin 81mg POdaily
Atenolol 100mg PO Daily
Cyanocobalamin 50mcg PO daily
Diltiazem HCl 300mg PO Daily
Hydrochlorothiazide 12.5mg PO daily
Pantoprazole 40mg PO Q24
Thiamine HCl 100mg PO daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
13. Metoprolol Succinate 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:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
hypothermia
alcohol withdraw
hematemesis
aspiration pneumonia
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**].
You came to the hospital with hypothermia, alcohol withdraw, and
vomited blood. We were not able to perform the endoscopy due to
your vital signs being unstable secondary to your alcohol
withdraw. You also had a pneumonia that was treated. We
provided you with medications that treated the withdraw and
treated you for GI bleed. You were discharged in stable
condition. You need to follow up with your doctors listed
below.
You need to complete you antibiotics (metronidazole and
levofloxacin) because you are being treated for pneumonia.
Please note we made the following changes to your medications.
STOPPED:
1. Atenolol 100 mg Tablet Sig: 1.5 Tablets PO once a day.
2. Diltzac ER 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
STARTED:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
once a day.
9. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO DAILY (Daily).
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You need to follow up with GI doctors to get [**Name5 (PTitle) **] EGD to evaluate
for the source of you bleed in your gut. You have an appointment
on Monday, [**1-15**] at 3:00 with Dr. [**First Name (STitle) 908**] [**Hospital Ward Name 516**], [**Hospital1 18**]
[**Hospital Unit Name 1825**] please book for EGD procedure by calling ([**Telephone/Fax (1) 667**].
Please call your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**] to have a
follow up evaluation within the week.
|
[
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"276.2",
"070.70",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11860, 11866
|
6396, 10069
|
292, 298
|
11972, 11972
|
3216, 3216
|
14201, 14725
|
2388, 2558
|
10312, 11837
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11887, 11951
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10095, 10289
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12151, 14178
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2573, 3197
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242, 254
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326, 1907
|
3233, 6373
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11986, 12127
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1929, 2191
|
2207, 2372
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,717
| 167,673
|
48401
|
Discharge summary
|
report
|
Admission Date: [**2164-5-11**] Discharge Date: [**2164-5-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
CC: fever, abd pain, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: [**Age over 90 **] yo M recent UTI on cipro p/w 7 hours fever, abd pain and
vomiting, chronic nonprod cough. In the ED, the patient was
found to have a new RLL infiltrate concerning for PNA (not seen
on CXR [**5-2**] done at NEBH), received ceftriaxone/flagyl for
community-acquired. He was tachycardic and borderline
hypotensive, unclear if SBP dropped below 90 mmHg at any point,
lactate 2.9 on presentation down to 1.9 with IVF. A RIJ central
line was placed. He received aggressive fluid resuscitation with
5L NS. RLL process appeared worse on his second CXR (after fluid
resuscitation). EKG was without concerning features (no
comparison available). Though his MS was near baseline per
family on admission, after becoming hypotensive his MS
deteriorated and he was given Haldol.
.
Labs notable for: low nl WBC count with 16% bands; Hct drop from
42% by CBC to 35% by VBG after IVF; BUN 24/Cr 1.2, likely some
renal insufficiency given his age and weight; AP 434, [**Doctor First Name **] 104;
TnT 0.03, other enzymes pending; urine concentrated, acidic,
otherwise clear. APACHE II score around 14, with subsequent
mortality estimate around 18%.
.
After receiving 5L NS in the ED, he was found to have worsening
hypoxemia, currently only 90% on 100%NRB face mask. The ED staff
discussed with the family regarding intubation, and they
ultimately agreed. Advised the ED to consider MRSA and resistant
GNRs, and to think about changing his abx to include Vanc and
either Ceftaz, Cefipime, Zosyn. Pt to be intubated shortly. ED
staff to re-examine pt and check repeat (3rd) CXR to look for
new pulm edema in setting of aggressive volume repletion, and to
give Lasix if evidence of new CHF.
.
ROS: unable to obtain as pt noncommnunicative
Past Medical History:
PMH:
-s/p CCY
-urinary spasm? (on Detrol)
-recent UTI (on Cipro recently)
*** apparently has not seen a doctor in years ***
.
Meds at home:
-Detrol
-Ativan
-Mucinex
-recent Cipro
Social History:
SH: lives at home with his wife; daughter is HCP; no known etoh
or drugs.
Family History:
FH: non contributory
Physical Exam:
PE
Vitals: T 103.4 , HR 107 , BP 100/60 , Vent settings : A/C TV
500cc ,RR 12 , PEEP 5, FiO2 100% SpO2 99 %
Gen: elderly man, lying in bed, sedated and minimally
interactive, no apparent distress
HEENT: NCAT, EOMI (tracking movements), MMM
Neck: supple
CV: distant, RRR, no M/R/G
Chest: + bronchial sounds, mild diffuse wheeze
Abd: soft, +abdominal muscle recruitment in exhalation
Ext: 1+ LE edema
Pertinent Results:
[**2164-5-11**] 06:19PM WBC-11.6* RBC-3.54* HGB-10.6* HCT-32.2*
MCV-91 MCH-29.9 MCHC-32.9 RDW-15.0
[**2164-5-11**] 03:40PM GLUCOSE-83 UREA N-21* CREAT-0.8 SODIUM-144
POTASSIUM-4.0 CHLORIDE-119* TOTAL CO2-16* ANION GAP-13
[**2164-5-11**] 06:19PM PT-18.6* PTT-43.2* INR(PT)-1.8*
[**2164-5-11**] 11:28AM TYPE-ART TEMP-39.4 RATES-[**11-3**] TIDAL VOL-500
PEEP-5 O2-100 PO2-261* PCO2-38 PH-7.31* TOTAL CO2-20* BASE XS--6
AADO2-411 REQ O2-72 INTUBATED-INTUBATED VENT-CONTROLLED
[**2164-5-10**] 10:35PM ALBUMIN-3.6 CALCIUM-9.0 PHOSPHATE-2.5*
MAGNESIUM-2.3
[**2164-5-10**] 10:35PM cTropnT-0.03*
Cardiology Report ECHO Study Date of [**2164-5-11**]
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Endocarditis.
Height: (in) 69
Weight (lb): 146
BSA (m2): 1.81 m2
BP (mm Hg): 132/47
HR (bpm): 105
Status: Inpatient
Date/Time: [**2164-5-11**] at 10:19
Test: Portable TTE (Focused views)
Doppler: Limited Doppler and color Doppler
Contrast: None
Tape Number: 2007E033-1:00
Test Location: East MICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aorta - Arch: *4.9 cm (nl <= 3.0 cm)
INTERPRETATION:
Findings:
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Suboptimal technical quality, a focal LV wall motion
abnormality
cannot be fully excluded.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Resting
tachycardia (HR>100bpm).
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free
wall motion are normal. There is no pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2164-5-11**] 17:21.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **]
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2164-5-11**] 9:05 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: assess for abscess
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with fever and bandemia.
REASON FOR THIS EXAMINATION:
assess for abscess
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: [**Age over 90 **]-year-old male with fever and bandemia.
Evaluate for abscess.
COMPARISON: None.
TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the
abdomen and pelvis from the lung bases to the pubic symphysis.
Multiplanar reformatted images were obtained.
CT OF THE ABDOMEN: The lung bases demonstrate patchy areas of
opacity, likely inflammatory. Basilar atelectasis and small
bilateral pleural effusions are identified.
No focal liver lesion is identified. The gallbladder is not
visualized. The spleen and adrenal glands are unremarkable. The
kidneys enhance and excrete contrast symmetrically. Multiple low
density lesions are seen within bilateral kidneys, the right is
more complex with septation. The pancreas demonstrates diffuse
calcification, which may represent chronic pancreatitis. A
hiatal hernia is present. Second portion of the duodenum is
somewhat dilated, the remainder of the small bowel is normal in
caliber, without evidence of obstruction. Large bowel is
unremarkable. The aorta is densely calcified. However, proximal
celiac, SMA, [**Female First Name (un) 899**] are opacified. There is small aneurysms of
bilateral renal arteries. No intra- abdominal free fluid, free
air is identified. No retroperitoneal or mesenteric
lymphadenopathy is appreciated.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum is fecal
loaded. The sigmoid colon is unremarkable. A Foley catheter is
seen within a decompressed bladder. The prostate is
unremarkable. No free fluid or lymphadenopathy is appreciated.
BONE WINDOWS: There is diffuse demineralization of the bones.
Multilevel degenerative changes are seen throughout the
thoracolumbar spine. Compression fracture of T12 is identified,
of undetermined chronicity. Mutiple Tarloff cysts are present.
THere is pagetoid change within both femurs and iliac bones.
IMPRESSION:
1. Small bilateral pleural effusions and adjacent compressive
atelectasis.
2. Diffuse calcifications throughout the pancreas likely
representing chronic pancreatitis.
3. Multiple low-density lesions within bilateral kidneys,
incompletely characterized.
4. Diffuse atherosclerotic calcifications throughout the aorta
and branch vessels.
5. Multilevel degenerative changes throughout the thoracolumbar
spine with compression deformity of T12 of undetermined
chronicity. There is diffuse demineralization of the bones.
6. No evidence of obstruction or intra-abdominal abscess.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2164-5-12**] 8:55 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2164-5-10**] 10:31 PM
CHEST (PORTABLE AP)
Reason: r/o infection
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with fever
REASON FOR THIS EXAMINATION:
r/o infection
AP PORTABLE CHEST, [**2164-5-10**], AT 2252 HOURS.
HISTORY: Fever.
COMPARISON: None.
FINDINGS: Lung volumes are low, with elevation of the left
hemidiaphragm. Linear atelectasis is seen in the left perihilar
region. There is an area of increased density in the right lung
base, which may represent pneumonia or aspiration. There is a
tortuous aorta. The cardiac silhouette is borderline enlarged.
No pleural effusion or pneumothorax is definitely seen on single
projection. There is a marked levoconcave scoliosis of the
thoracic spine. The bones are diffusely osteopenic.
IMPRESSION: Increased density in the right lung base may
represent pneumonia, aspiration, or atelectasis. Correlate
clinically.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: FRI [**2164-5-11**] 6:45 AM
Brief Hospital Course:
A/P: [**Age over 90 **] yo M s/p recent UTI on cipro who p/w fever, abd pain and
vomiting, found to have a new RLL infiltrate, shock, hypoxemic
resp failure after aggressive fluid resuscitation necessitating
intubation. Improved during hospital course on empiric
antibiotics and respiratory support and was successfully
extubated [**2164-5-13**].
.
1. RLL pneumonia: likely aspiration PNA. Improving per f/u CXR
[**2164-5-13**]
- continue empiric abx treatment with Vanc, Zosyn, and Flagyl
for total of [**2-28**].
- sputum cultures grew MRSA
- he improved significantly after 4th day and was extubated on
day 3.
- he should finish course of antibiotics for additional 6 days
.
2. Hypoxemic resp failure: Cause of respiratory failure was
pneumonia in setting of chronic respiratory failure and
aspiration. Successfully extubated [**2164-5-13**] at 16:00. 02 sats on
[**2164-5-14**] between 91-97 now on NC 3.0 and albuterol nebs.
- ordered speech and swallow study ([**12-23**] coughing with water)
cleared patient to tolerate thickened liquids
- continue to follow 02 sats
.
3. Sepsis: Presumed source was the PNA, no loci of infection
found in abdomen/GU with negative CT abdomen/pelvis. cdiff
negative x 3 (although presumed infection due to infected
partner), legionella neg x 1. Sepsis resolved after 1st 24 hours
after 11 liters of fluid resuscitation. Was on neosynephrine for
less than 24 hours.
- Continue Abx as above
.
4. Paroxysmal atrial fibrillation: During hospital course,
patient had episode of afib in the setting of infection. The
rhythm spontaneous converted before treatment with amiodarone.
Patient is currently NSR.
- follow EKG. Has been NSR
5. Elevated PTT: During hospital course was found to have an
elevated PTT secondary to infection. Values returned to [**Location 213**]
and DIC workup negative, Continue to follow PT/PTT/INR, most
likely secondary to poor diet, low vitamin K.
.
6. Elevated alk phos: also in the setting of cholestasis and
sepsis, which decreased from 434 to 248 to 232. RUQ ultrasound
negative and LFTs wnl.
.
7. Activity: bedrest recommended
8. FEN: now cleared to have thickened liquids.
- volume status given aggressive fluids: goal output 1L with
lasix 20mg
9. PPx: SC heparin; PPI; bowel regimen
10. Access: RIJ was placed in ER [**2164-5-10**].
11. Comm: family (daughter)
12. Code: DNR/DNI per family meeting [**2164-5-13**]
13. Dispo: social work eval ordered. Projected dispo is to
[**Hospital 100**] Rehab.
Medications on Admission:
Meds at home:
-Detrol
-Ativan
-Mucinex
-recent Cipro
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Sepsis, Resolved RLL pneumonia, Respiratory failure, Paroxysmal
atrial fibrillation
Discharge Condition:
Stable, oxygenation improved
Discharge Instructions:
- Continue antibiotics are written in discharge summary
- Follow EKG (telemetry) with history of paroxysmal atrial
fibrillation event
- Follow diet recommendations to prevent aspiration
- Please return to ED if patient has fever, shortness of breath,
chest pain, or any symptoms of concern.
Followup Instructions:
Please follow up with primary care physician at [**Hospital 100**] Rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"785.52",
"507.0",
"584.9",
"482.41",
"427.31",
"995.92",
"585.9",
"038.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11870, 11936
|
9287, 11766
|
292, 298
|
12063, 12093
|
2840, 3500
|
12432, 12637
|
2382, 2405
|
8319, 8362
|
11957, 12042
|
11792, 11847
|
12117, 12409
|
3526, 4998
|
2420, 2821
|
223, 254
|
8391, 9264
|
326, 2071
|
5030, 5247
|
2093, 2274
|
2290, 2365
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,631
| 107,788
|
13774
|
Discharge summary
|
report
|
Admission Date: [**2119-11-12**] Discharge Date: [**2119-11-21**]
Date of Birth: [**2067-3-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Toradol / Compazine /
Morphine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
RIJ Cordis line placement [**11-12**], changed to central line [**11-18**]
History of Present Illness:
This is a 52 y/o female with h/o UGI bleed with duodenal ulcers,
DVT/PE, afib, anticoagulated with coumadin who is admitted with
hematemesis and hematocrit of 15.4. Patient was recently
admitted [**2119-10-29**] to [**Hospital1 **] with melena and INR 5.5. She had an
EGD and colonoscopy which showed duodenitis, and features
suggestive of duodenal ulcer, and diverticulosis. She was h.
pylori negative and she never required any blood transfusion as
hct was stable at baseline to 32. Patient was sent home on
coumadin and lovenox as a bridge. She reports her INR was 1.7
last Tuesday. Beginning on Friday the patient had coffee ground
emesis, but none significant since last night. She also noticed
black stools this morning. She didn't want to come in earlier
b/c she was afraid of getting a blood transfusion. Patients InR
on admission was 4.9 and hct was 15. Blood pressure was slightly
low with systolics in the 90s, patient was not tachycardic. She
has had some intermittent epigastric abdominal pain, none on
admission. Does have some right sided chest pain since her PE 1
year ago. She got 1 L IVF and a 16 G PIV and then was
transferred up to the ICU for further transfusions and
monitoring. In the ICU patient given FFP and vitamin K to
reverse INR and transfused 6 units of PRBC. After reversal of
coumadin and blood transfusion patient's Hct remained stable. GI
following in ICU and deferred immediate EGD given recent
negative EGD. Also while in the ICU patient was complaining of
RUQ pain and an U/S was ordered which showed dialation of common
bile duct without any evidence of stones and also left mid wall
fluid collection that represents a chronically infected or
inflammatory fluid collection, and atrophic right kidney. Based
on these findings a CT scan of abdomen was ordered. Patient
currently still with abdominal pain but states the IV diluadid
is helping.
Past Medical History:
PMH:
s/p DVTs and PEs (most recently within last 3 months)
UGIB while on Coumadin (No documentation)
Myofascial pain syndrome
Migraines
Pseudotumor cerebri
Praoxysmal AFIB
GERD
PUD
Parotid Gland Tumor
Past Psych Hx:
The patient reports seeing a psychiatrist once many years ago to
work through grief over her mother's death. The patient
acknowledges that her Neurologist had her involuntarily admitted
to a psychiatric facility for reported delusion of her body
being infested with mice, but says this was a false accusation.
Social History:
Social History:
Social/Substance Abuse History:
The patient is a retired nurse (now works as organist).and has
been married for over 30 years and lives at home with husband.
The patient states she has two sons who live in the area. She
states that she smokes 2 cigarettes a day at most. She denies
any history of alcohol or drug abuse, denies detoxes, seizures
or DTs in the past. Patient did report to one nurse that she
occasionally takes extra of her oxycontin due to severe
pain.There is a history in the chart of domestic violence on the
part of her husband. She lives with her husband and 29yo son.
Family History:
Family History:
Mother had lupus and ?blood clots.
She denies any psychiatric illness among her family, however.
Physical Exam:
PE: T 99.1 HR 75 BP 99/65 RR 16 95% on 4 L NC
GEN: overweight very pale female, anxious, odd affect
HEENT: perrl, eomi, dry mucus membranes, pale conjucntiva
NECK: supple, no masses, scar from recent left ej seen.
CV: rrr s1s2
LUNgS: CTA b/l
ABD: mild tenderness in epigastric/ruq area
EXT: no edema
REctal: per GI fellow black OB+ stools
Neuro: alert and oriented x 3, otherwise grossly nonfocal
Pertinent Results:
[**2119-11-12**] 03:51PM HGB-4.6* calcHCT-14
[**2119-11-12**] 03:30PM GLUCOSE-122* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
[**2119-11-12**] 03:30PM ALT(SGPT)-34 AST(SGOT)-48* ALK PHOS-125*
AMYLASE-30 TOT BILI-0.2
[**2119-11-12**] 03:30PM LIPASE-42
[**2119-11-12**] 03:30PM TOT PROT-6.1*
[**2119-11-12**] 03:30PM WBC-8.2 RBC-1.69*# HGB-4.8*# HCT-15.4*#
MCV-91 MCH-28.1 MCHC-30.9* RDW-16.8*
[**2119-11-12**] 03:30PM NEUTS-72.9* BANDS-0 LYMPHS-22.2 MONOS-3.8
EOS-0.7 BASOS-02
[**2119-11-12**] 03:30PM PLT COUNT-359#
[**2119-11-12**] 03:30PM PT-24.2* PTT-29.8 INR(PT)-4.3
CXR: IMPRESSION: No evidence for CHF or pneumonia. The pulmonary
vasculature is unremarkable.
Brief Hospital Course:
A/P: 52 y/o F with h/o duodenal ulcers and GIB while
anticoagulated for afib/pe/, initially admitted to MICU with
hematemesis and significant hct drop with supratherapeutic inr,
now transferred to medicine floor for further management.
.
1. GI Bleed: The pt's GIB was thought likely to be resulting
from her duodenal ulcers and supratheraputic INR. It was unclear
if the pt was noncompliant with PPI therapy vs if her GIB was
secondary to PPI resistance or failure. The pt initially
required 6 units PRBCs transfusion and Vitamin K on initial
admission to the MICU but her Hct had been stable since transfer
to the floor and she remained hemodynamically stable. Records
from [**Hospital **] hospital re: prior bx results and EGD performed in
[**2116**] showed antral gastritis and prepyloric ulcer. GI followed
the patient while in house and decided to defer EGD for now as
the pt had a recent EGD and her Hct remained stable. The pt
required no further transfusions while on the medical floor she
remained on IV PPI [**Hospital1 **] until her discharge. She had very poor
IV access and had a RIJ cordis in place until this was changed
to a triple lumen catheter. Ultimately, the patient requested
that she have EGD performed under general anesthesia and she is
currently scheduled for EGD for [**Month (only) **] under general
anesthesia which was arranged by GI. Her coumadin will need to
be held 5 days prior to her procedure.
2. ?abdominal wall fluid collection: U/S on [**11-13**] showed a fluid
collection in her abd wall which was not communicating with the
bowel and likely represented a chronically inflamed or infected
fluid collection. This was thought to be likely secondary to
heparin or lovenox injections. NO further abdominal imaging was
performed.
.
3. PE/DVT: After thorough investigation into pt's history of PE,
it was found that CTA [**2119-9-29**] from OSH records showed small
subsegmental RUL and RML PE, but subsequent imaging here at
[**Hospital1 18**] had not shown PEs (CTA here at [**Hospital1 18**] [**2119-10-2**] showed
resolution of PE and CTA [**10-23**] revealed no definite PE although
there was decreased attenuation in subsegmental RML). We had
these scans re-read by radiology on this admission and radiology
confirmed that the original CTA done on [**2119-9-29**] at [**Location (un) 620**] did
show a very small subsegmental RML PE which had resolved on
subsequent CTAs here at [**Hospital1 18**] (in the interim, pt had been
treated with heparin). The radiologist had hypothesized that it
was possible that a pulmonary embolus could clear after only 3
days of therapy given how small the clot burden appeared to be
on the original CTA done at [**Location (un) 620**]. In addition, it was
confirmed that the patient only had episodes of superficial
thrombophlebitis and never had a confirmed DVT. The pt had been
anticoagulated since [**Month (only) 216**] for PE as well as afib and had had 2
episodes of GIB since requiring several PRBC transfusions. The
medicine team on this admission had an extensive discussion with
the patient re: the risk of continuing anticoagulation therapy
with no current evidence of pulmonary embolus in the setting of
a large duodenal ulcer. The patient was very focused on her
diagnosis of pulmonary embolus and after much discussion, the
decision was made to continue anticoagulation given the
patient's discomfort in stopping anticoagulation. The patient
was kept in house with heparin drip as bridge until her INR
reached 2.0. She was discharged with instructions to follow her
INR closely at her PCP's office.
4. Right pleuritic chest pain: Pt has had complaints of this
several times in the past and was being treated for a PE. EKGs
repeatedly remained unchanged. The etiology for this pain was
unclear but was thought to be likely musculoskeletal.
5. UTI: pt had evidence of a UTI on urinalyis and was treated
with Cipro [**Hospital1 **] for a 3 day course.
.
6. Afib: Pt remained in afib, rate controlled, and
anticoagulated with heparin and coumadin. She remained on a B
blocker while in house and was discharged on her outpatient dose
of Atenolol.
7. Chronic pain: Pt was continued on oxycontin and percocet prn
per her outpatient regimen for chronic pain related to her
pseudotumor cerebri.
.
8. Psych: Pt had some history of psychiatric
hospitalization/delusions in the past but this has never been
formally evaluated by psychiatry. She definitely lacked
insight into her disease process and it was often difficult to
address the complex medical issues re: her GIB risk and
anticoagulation for PE. She was continued on clonazepam and
ativan prn.
9. Hypothyroidism - She was continued on levoxyl
.
10. Code: full.
11. Access: this was extremely difficult to obtain. Pt had a
RIJ cordis placed initially on ICU admission which then was
changed to a triple lumen catheter and remained in place until
her discharge.
12. Dispo: Patient was discharged after her INR was therapeutic
with instructions to follow up the next day for a follow-up INR
check. She will need to return in [**Month (only) **] for EGD under
general anesthesia per her request.
Medications on Admission:
protonix 40 [**Hospital1 **]
levoxyl 100 qd
oxcontin 40 [**Hospital1 **]
albuterol inh rpn
atrovent inh prn
clonopin 1 tid prn
risperdal 1 po hs
atenolol 25 qd ca;coi,
coumadin and lovenox stopped friday
percocet prn
-
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
[**Hospital1 **]:*28 Tablet Sustained Release 12HR(s)* Refills:*0*
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
[**Hospital1 **]:*21 Tablet(s)* Refills:*0*
3. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Hospital1 **]:*7 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
[**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
[**Hospital1 **]:*14 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*14 Tablet(s)* Refills:*0*
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*14 Tablet(s)* Refills:*0*
9. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. GI bleed
2. Peptic ulcer disease
3. Atrial fibrillation
4. h/o PE
Discharge Condition:
Stable
Discharge Instructions:
Please continue to take all medications as you were previously
taking. You should resume your Coumadin dose at 6 mg QHs.
You will need to have your Coumadin dosage and INR monitored
very closely so that you do not have any further instances of GI
bleeding, so you should plan to go to your PCP's office tomorrow
to have your INR checked.
Please return to the ED or call your PCP if you experience any
worsening abdominal pain, nausea or vomiting, dark or tarry
stools, blood in your stool, dizziness or lightheadedness, or
any other concerning symptoms.
Followup Instructions:
You will need to have your INR checked by your PCP tomorrow and
likely every day this week for goal INR 2.0-2.5. Your PCP will
then adjust your coumadin dosage.
The gastroenterologists have set up your outpatient EGD under
general anesthesia for [**1-4**] at 2 pm (see below). Please keep
this appointment and stop taking your Coumadin 5 days prior to
your procedure. You will need to have your INR checked one day
prior to the procedure and those results should be emailed to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by your PCP:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2120-1-4**] 2:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2120-1-4**]
2:00
Completed by:[**2119-12-3**]
|
[
"790.92",
"348.2",
"599.0",
"280.0",
"682.2",
"786.52",
"532.00",
"244.9",
"427.31",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11467, 11473
|
4817, 9970
|
341, 418
|
11586, 11595
|
4068, 4794
|
12199, 13184
|
3537, 3636
|
10239, 11444
|
11494, 11565
|
9996, 10216
|
11619, 12176
|
3651, 4049
|
290, 303
|
446, 2328
|
2350, 2880
|
2912, 3505
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,409
| 196,008
|
48673
|
Discharge summary
|
report
|
Admission Date: [**2112-8-3**] Discharge Date: [**2112-8-9**]
Date of Birth: [**2059-11-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
EGD, colonoscopy
History of Present Illness:
Mr. [**Known lastname 6632**] is a 52 year old man with a long history of alcohol
abuse. He presented today to the ED with generalized weakness.
Per patient, he has been feeling worse over the last 20 days. He
denies any specific event that occurred at that time. He states
that his PO intake has been diminished since that time secondary
to 2-3 episodes of emesis a day. He describes the emesis as
clear to whitish. He reports difficulty with solid foods, but
has been able to tolerate liquids. He reports drinking alcohol 5
days a week. He states he drinks two 12 oz beers and "a couple"
of shots of rum or vodka on days that he drinks.
.
He has been having a productive cough with non-bloody phlegm. He
reports it looks "normal," but does not describe further. When
he has a forceful cough, he will also vomit at the same time. He
has been having loose stool for about 1 week. He describes it as
pale yellow and non-bloody. He also notes that his urine color
has turned darker during this time. He thinks that he has lost
about 15 lbs over the last 1-2 months. Mr. [**Known lastname 6632**] also notes
he fell last Friday. He hit his head at home and lost
consciousness briefly. Following the incident, he slept on the
couch. He reports feeling so fatigued over the last couple of
days, that he has not stood up. However, he reports being
independent with all of his daily activities. Because of his
fatigue, he called EMS for evaluation.
.
In the ED, initial vs were: T97.3 P110 BP100/64 97% O2 sat. He
had one low blood pressure in the 80's that responded to fluid.
He was given a total of 3 L of IVF with the last liter
containing 40 mEq KCl. Labs were significant for a potassium of
2 and sodium of 118. He had a CT which showed some ground glass
opacities in the lungs and circumferential thickening of the
esophagus.
.
On the floor, he denied any specific pain. He stated he felt
fatigued and just wanted to drink some water.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied shortness of
breath. Denied chest pain or tightness, palpitations. Denied
abdominal pain. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Chronic neck pain, s/p C5-C6 surgery [**26**] yrs ago
Chronic lower back pain, s/p lumbar discectomy 10 yrs ago
Hemorrhoids with history of rectal bleeding
H/o seizure (generalized tonic-clonic), likely related to EtOH
withdrawal
H/o post-concussive headache
Depression/anxiety
Vitamin D deficiency
Tobacco abuse
Social History:
He lives alone. Works as a garbage collector. Previously used
multiple illicit substances, none currently. Smokes 1 PPD, down
from 2 PPD. Reports alcohol intake occurring 5 days a week.
Reports 2 12 oz beers and a couple of shots. Reports he does not
have a support system
Family History:
Mother had HTN, then died of a mouth cancer/MI at age 58. Father
with lung CA and died of MI at 68.
Physical Exam:
Vitals: T: 97.9 BP: 109/67 P: 97 R: 13 O2: 99 on RA
General: Alert, oriented, appears comfortable
HEENT: slight scleral icterus, MMM, face symmetric, EOMI
Lungs: Occasional scattered rhonchi that improve with clearing
CV: tachycardic
Abdomen: soft, non-tender, slightly distended, bowel sounds
present, no rebound tenderness or guarding, liver edge slightly
enlarged, no [**Doctor Last Name 515**] sign
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, [**6-16**] plantar/dorsiflexion, knee flexion/extension, hip
flexion, grip strength, arm flexion/extension
Pertinent Results:
Admission Labs: [**2112-8-2**] 10:00PM
PT-14.2* PTT-33.2 INR(PT)-1.2*
WBC-11.1*# RBC-3.12* HGB-11.8* HCT-30.8* MCV-99* PLT COUNT-54*
cTropnT-0.01
LIPASE-157*
ALT(SGPT)-51* AST(SGOT)-90* LD(LDH)-327* ALK PHOS-107 TOT
BILI-3.7*
GLUCOSE-126* UREA N-22* CR-1.0 SODIUM-118* POTASSIUM-2.0* CL-68*
CO2-31
Head CT [**2112-8-2**]: No acute intracranial process
CT TORSO [**2112-8-2**]:
1. Upper lobe paraseptal emphysema. Bilateral multifocal
ground-glass opacities, nonspecific.
2. Fatty liver.
3. Circumferential thickening of the esophagus.
4. Fatty infiltration in the wall of the ascending and
transverse colon which can be seen in chronic inflammatory bowel
disease.
TTE [**2112-8-3**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Labs on Discharge:
[**2112-8-8**] 07:10AM BLOOD WBC-6.3 RBC-2.45* Hgb-9.0* Hct-25.8*
MCV-105* MCH-36.7* MCHC-34.8 RDW-15.7* Plt Ct-107*#
[**2112-8-8**] 07:10AM BLOOD Glucose-81 UreaN-12 Creat-0.6 Na-137
K-4.0 Cl-101 HCO3-29 AnGap-11
[**2112-8-8**] 07:10AM BLOOD ALT-52* AST-74* AlkPhos-92 TotBili-2.1*
[**2112-8-3**] 10:46PM URINE RBC-3* WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
[**2112-8-3**] 10:46PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-5.5 Leuks-NEG
.
Blood culture: No growth to date.
Brief Hospital Course:
52 yo M with EtOH abuse admitted with weakness, found to have
multiple, severe electrolyte abnormalities, mild EtOH hepatitis
and acute on chronic anemia.
He was admitted to the ICU in management of his weakness and
impressive metabolic derangements. His Na was depressed to 118,
accompanied by severe hypokalemia (2.0), hypomagnesemia (1.3),
and a metabolic alkalosis, all of which can be explained by
recent hypovolemia from poor PO intake. His urine was highly
concentrated (SG>1.039 and osm 490) with urinary sodium less
than assay. His elevated lactate and [**Last Name (un) **] also speak to this
diagnosis. His electrolytes all gradually improved with
aggressive potassium, magnesium repletion and normal saline
resuscitation. His phosphate was dangerously low (0.9),
suggesting possible refeeding syndrome as his PO intake
improved. His phosporus was aggressively repleted. He did not
develop re-feeding syndrome and with the assistance of a
dietician was taking in a full diet with stable electrolytes in
the days prior to discharge. The patient should have repeat chem
10 at the time of follow-up.
He was also found to have transaminitis with evidence of fatty
liver on his CT torso. He may have a component of NASH as well
as probable mild alcoholic heatitis. His hep serologies showed
exposure/vaccination against [**Last Name (un) **], though negative hep B and C.
His discriminate function was 14 so no steroids were given. His
electrolytes downtrended with fluid rescucitation. He was seen
by the social work team for alcohol abuse counseling. Social
work raised concern for memory and/or cognitive deficits
associated with chronic alcoholism. He refused enrollment in an
alcohol rehabilitation program.
The GI team was consulted due to the finding of thickened
esophageal wall on CT chest and acute on chronic anemia in the
setting of guaiac positive stool. He did have 1U PRBC's
transfused during this hospitalization with appropriate increase
in Hct. EGD revealed Z-line irregularity, gastritis and
duodenitis. He was placed on a PPI and must follow-up with his
PCP for biopsy results of the esophagus, stomach and duodenum.
The patient understood the risks, including death, of not
following up and assured this writer that he would. Colonoscopy
showed 2 polyps in the colon, both of which were removed. Due to
poor prep and a large polyp, it is recommended that he return
for repeat colonoscopy in 8 weeks. He should have a repeat CBC
on follow-up at his PCP's office.
Medications on Admission:
No medications prior to admission
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. multivitamin with folic acid 200 mcg Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Outpatient Lab Work
Blood draw: Chem 10, LFT's, CBC. To be drawn at the time of your
follow-up appointment.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Alcoholic hepatitis
Hyponatremia (low sodium)
Hypokalemia, hypomagnesemia, hypophosphatemia, hypocalcemia
Metabolic alkalosis
Malnutrition
Anemia of chronic disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with weakness. You were found to have extreme
electrolyte abnormalities in the blood due to chronic alcohol
use and malnutrition. You were treated with IV fluids and
electrolyte repletion. Please have your blood drawn at your
follow-up visit with your doctor [**First Name (Titles) **] [**Last Name (Titles) 19697**] your electrolytes.
Continue taking multivitamins as prescribed.
You also had evidence of liver disease related to your alcohol
use. It is extremely important that you quit drinking, as this
condition could be life threatening. [**Last Name (Titles) **] your liver tests
when you see your primary care doctor.
Your blood counts were very low due to chronic alcohol use and
malnutrition. You required a blood transfusion. You were found
to have some inflammation of your stomach and small bowel and an
irregularity at the transition point of the esophagus to the
stomach. Follow-up the results of the biopsies that were taken
during your endoscopy - you can get these results at your
follow-up appointment with your primary care doctor. It is
essential that you follow this up as this could be due to a life
threatening condition and further treatment may be required.
Take the prescribed medication called pantoprazole to reduce
acid production and hopefully allow healing of the inflammation.
Have your blood counts checked when you follow-up with your
primary care doctor.
You also had polyps removed from your colon. Please have a
repeat colonoscopy as scheduled.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2112-8-22**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Repeat colonoscopy [**2112-10-3**] at 9am, arrive at 8AM to the
outpatient GI procedure/colonoscopy area.
|
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icd9cm
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[
[
[]
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icd9pcs
|
[
[
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8982, 9001
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9210, 9210
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2,493
| 130,609
|
2884
|
Discharge summary
|
report
|
Admission Date: [**2113-5-17**] Discharge Date: [**2113-6-2**]
Date of Birth: [**2049-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Protonix
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**5-18**] Left Carotid Stent
[**5-23**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag,
SVG to OM, SVG to PDA)
History of Present Illness:
This is a 64 y/o male with a h/o left embolic stroke in [**3-15**].
During that hospitalization he experienced angina. Underwent
cardiac cath that revealed severe three vessel disease. During
work-up for stroke, was found to have severe left carotid
stenosis. Therefore he is being admitted to undergo intervention
on his left carotid artery and coronary arteries.
Past Medical History:
History of Embolic Stroke, Coronary Artery Disease, s/p
PTCA/stents [**2106**], Diabetes Mellitus, Hypertension, Emphysema,
Chronic Pancreatitis, Gastroesophageal Refulx Disease, Chronic
renal insufficiency, Hepatitis C, Trauma to left eye
Social History:
Lives alone in Dochester. Distant alcohol abuse. No smoking.
Going to school for his GED; until now functionally illiterate,
but has learned to read, though basic math still difficult.
Family History:
Mother had stroke in her 60s.
Physical Exam:
VS: 68 20 132/61
Gen: WDWN male in NAD
Skin: W/D, -lesions
HEENT: Blind Left Eye, Perrl right eye, Dentition fair
Neck: Supple, FROM, 2+ Bilat Carotid Bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses
throughout
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2113-5-17**] 04:55PM BLOOD WBC-5.3 RBC-3.88* Hgb-10.6* Hct-33.9*
MCV-87 MCH-27.3 MCHC-31.3 RDW-13.6 Plt Ct-214
[**2113-5-17**] 04:55PM BLOOD PT-12.6 PTT-30.9 INR(PT)-1.1
[**2113-5-17**] 04:55PM BLOOD Glucose-65* UreaN-20 Creat-1.9* Na-140
K-5.2* Cl-109* HCO3-25 AnGap-11
[**2113-5-20**] 05:15AM BLOOD ALT-15 AST-17 LD(LDH)-182 AlkPhos-105
Amylase-212* TotBili-0.3
[**2113-5-17**] 04:55PM BLOOD Calcium-9.4 Phos-2.5* Mg-2.1
[**2113-6-2**] 06:07AM BLOOD WBC-10.5 RBC-3.17* Hgb-9.0* Hct-27.6*
MCV-87 MCH-28.2 MCHC-32.4 RDW-13.9 Plt Ct-620*
[**2113-6-2**] 06:07AM BLOOD Glucose-112* UreaN-26* Creat-2.3* Na-139
K-5.1 Cl-107 HCO3-23 AnGap-14
[**2113-5-31**] 05:12AM BLOOD Glucose-131* UreaN-34* Creat-2.2* Na-141
K-5.3* Cl-109* HCO3-23 AnGap-14
[**2113-5-30**] 03:39AM BLOOD Glucose-65* UreaN-35* Creat-2.2* Na-140
K-3.8 Cl-106 HCO3-22 AnGap-16
[**2113-5-31**] 05:12AM BLOOD Amylase-66
[**2113-5-30**] 03:39AM BLOOD ALT-30 AST-21 LD(LDH)-217 AlkPhos-62
Amylase-84 TotBili-0.5
[**2113-5-30**] 03:39AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.7*
[**2113-5-31**] Abdominal Ultrasound: The liver is normal in echo
texture with no focal lesions identified. There is no
intrahepatic ductal dilatation. The common bile duct measures 7
mm in its proximal free segment. The distal common bile duct and
pancreas cannot be visualized. There is appropriate forward
portal venous flow. There is no perihepatic ascites.
[**2113-5-26**] Abdominal CT Scan: 1. Findings consistent with chronic
pancreatitis. No CT evidence of acute on chronic pancreatitis.
2. Essentially unchanged appearance of the pancreas since
[**2106-3-12**]. 3. Pneumobilia. 4. Diverticulosis without evidence of
diverticulitis.
Brief Hospital Course:
Initially admitted under Vascular Service and underwent
successful left carotid stent placement on [**5-18**] by Dr.
[**Last Name (STitle) **]. Postoperatively experienced hematuria related to
traumatic foley placement. He was followed closely by the
urology service which recommended to continue foley catheter
with void trial after surgical revascularization surgery. Over
several days, his hematuria improved. He otherwise remained pain
free on medical therapy. On [**5-23**], Dr. [**Last Name (STitle) **] performed
coronary artery bypass grafting surgery. For surgical details,
please see seperate dictated operative note. Following the
operation, he was brought to the CSRU for invasive monitoring.
Initially hypertensive, he required aggressive blood pressure
management. He also experienced persistent hyperkalemia which
was intermittently treated with glucose, insulin, kayexelate,
and intravenous lasix. He otherwise maintained stable
hemodynamics and remained in a normal sinus rhythm. On
postoperative day one, he awoke neurologically intact and was
extubated without incident. Early postop, he complained of
nausea and vomiting. Given chronic pancreatitis, he was
initially kept NPO, with nasogastric tube in place and general
surgery was consulted. White count was only slightly elevated.
Pan cultures remained negative. Abdominal ultrasound and CT
scans were obtained which found no evidence of acute
pancreatitis. Over several days, his abdominal symptoms
gradually improved as did his white count and amylase levels.
The NGT was eventually removed and he was started clear liquids.
He made slow but steady progress and eventually transferred to
the SDU on postoperative day seven. Foley was removed and he was
voiding without difficulty. His diet was slowly advanced. As
expected, he continued to experience abdominal pain given his
chronic pancreatitis. He should followup with Dr. [**Last Name (STitle) **] as
an outpatient to continue management of his chronic pain. Prior
to discharge, the pain service was consulted and recommended
Neurontin in addition to his narcotics. His renal function
postop remained relatively stable with creatinine ranging from
1.9 - 2.3. He remained in a normal sinus rhythm without atrial
or ventricular arrhythmias. He continued to make clinical
improvements with diuresis and was eventually cleared for
discharge to home on postoperative day 10.
Medications on Admission:
In house: Plavix 75mg qd, Lipitor 80mg qhs, Glyburide 1.25mg qd,
Imdur 30mg qd, Lopressor 50mg [**Hospital1 **], Aspirin 325mg qd, Nitro gtt,
Neo gtt, Keflex 250mg q8hr, Percocet
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*1*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*1*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO daily ().
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Left Carotid Stenosis s/p Left Carotid Stent
PMH: h/o Embolic Stroke, s/p PTCA/stents [**2106**], Diabetes
Mellitus, Hypertension, Emphysema, Chronic Pancreatitis,
Gastroesophageal Refulx Disease, Chronic renal insufficiency,
Hepatitis C, Trauma to left eye (blind)
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-11**] weeks, call for appt
Local cardiologist in [**3-11**] weeks, call for appt
Completed by:[**2113-6-2**]
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icd9cm
|
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7397, 7454
|
3371, 5770
|
285, 410
|
7824, 7830
|
1670, 3348
|
8295, 8499
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,035
| 170,826
|
16127
|
Discharge summary
|
report
|
Admission Date: [**2152-8-24**] Discharge Date: [**2152-9-21**]
Date of Birth: [**2089-12-13**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
acute on chronic renal failure
Major Surgical or Invasive Procedure:
TIPS, complicated by portal vein branch perforation with no
resultant bleeding or hemodynamic instability.
HD permanent catheter placement [**9-18**]
History of Present Illness:
Ms. [**Known lastname **] is a 62 y/o F hx NASH cirrhosis recently admitted to
[**Hospital1 18**] for volume overload and IV diuresis with hospital course
complicated by an UGIB and variceal banding who was discharged
on [**2152-8-19**] to home.
.
She returns today from home having been called in by her
hepatologist for inpatient management of worsening renal
function and increased volume overload. At routine labs drawn
yesterday, her creatinine was 2.5 up from 1.6-1.8 baseline and
she had gained 4 pounds in 2 days. Her weight at last discharge
was 104.5kg.
.
Today, she reports that since discharge she attended her son's
wedding. At the wedding, she reports no dietary indiscretion,
altthough the food was more [**Doctor First Name **] than usual. That night, she
started [**Doctor First Name **] ave nausea, but did not vomit. She also started to
have waterry diarrhea up to 4 times a day on Saturday through
Sunday. On Monday, she felt a bit better, had no diarrhea, but
continued to feel nausea. Tuesday, she had 4 episodes of
diarrhea, nonbloody, non melanic. She did receive zofran from
Dr. [**Last Name (STitle) 497**] with mild improvement of nausea. Yesterday she was
seen in clinic by Dr. [**Last Name (STitle) 497**] with routine labs drawn, which were
noted today to have an elevation in creatinine to 2.5 as well as
increase in weight.
.
She denies any fevers, chills, abdomnial pain, cough, pleuritic
pain. + DOE which has not changed from baseline. No CP,
palpitations. No hemetemesis, no melena, BRBPR. Since last EGD,
she has continued to feel a sensation of food stuck in her
throat with swallowing. + worsening heartburn sensations.
Past Medical History:
NASH/Cirrhosis: (Liver bx [**9-6**] = Stage IV cirrhosis, Grade 2
inflammation)
EGD [**7-13**] = 3 cords of grade 1
Thrombocytopenia
Previous ascites and encephalopathy
GERD
DM2 with retinopathy
HTN
Retinal hemmorhape; diabetic retinopathy
Diabetic neprhopathy
sleep apnea
Leg crams/? RLS
DJD of neck
? ASD/murmur on exam
Hyperdymanic LVF (75% on echo 1 yr ago
Intermittent, atypical CP (stress test had been planned but not
done).
H/o Dermoid cyst
Right adrenal mass
.
Past Surgical History:
s/p cholecystectomy followed by tubal ligation, s/p left
oopherectomy, s/p Appy
.
Past Psychiatric History:
Psychiatrist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; Psychologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Depression first experienced in HS
First hospitalization in [**2131**] (after husband's death).
12 previous psychiatric hospitalizations in all
Most recently treated at [**Doctor First Name 1191**] (and transferred to Bay State)
in [**2146-3-11**].
H/o cutting and burning self.
H/o OD on meds in SA.
h/o 1 course of ECT in past that was helpful
Social History:
Widowed, lives in [**Hospital3 **] and recently do to meds
non-compliance, they are giving her meds at [**Hospital3 **]
Has 4 children, several in MA
Smoking: none
EtOH: never
Illicits: none
Family History:
Mom: CAD, stroke
Dad: HTN, DM
Physical Exam:
PE: 100.1 129/52 64 18 96%RAO2 Sats
Gen: pleasant, NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: III/VI systolic murmur, no rubs
LUNGS: CTAB
ABD: Soft, distended, non-tender, no fluid wave
EXT: 1+ edema in LE
SKIN: No lesions
MSK: left wrist in splint, no swelling, minor ecchymosis
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-9**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2152-8-9**] LIVER ABD U/S: IMPRESSION:
1. Heterogeneous and coarsened liver without focal lesion.
2. No ascites.
3. Splenomegaly.
4. Left lower quadrant cystic structure. Pelvic ultrasound to
further
evaluate continues to be recommended.
[**2152-8-24**] 03:00PM GLUCOSE-87 UREA N-56* CREAT-2.7* SODIUM-134
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14
[**2152-8-24**] 03:00PM estGFR-Using this
[**2152-8-24**] 03:00PM CK(CPK)-106 TOT BILI-0.5
[**2152-8-24**] 03:00PM CK-MB-2 cTropnT-<0.01
[**2152-8-24**] 03:00PM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-4.5
MAGNESIUM-2.7*
[**2152-8-24**] 03:00PM WBC-5.4 RBC-2.99* HGB-8.9* HCT-27.0* MCV-90
MCH-29.8 MCHC-32.9 RDW-19.1*
[**2152-8-24**] 03:00PM PLT SMR-LOW PLT COUNT-99*
[**2152-8-24**] 03:00PM PT-16.4* PTT-26.1 INR(PT)-1.5*
[**2152-8-24**] 02:47PM URINE HOURS-RANDOM
[**2152-8-24**] 02:47PM URINE HOURS-RANDOM UREA N-219 CREAT-64
SODIUM-66
[**2152-8-24**] 02:47PM URINE OSMOLAL-294
[**2152-8-24**] 02:47PM URINE VoidSpec-UNLABELED
[**2152-8-24**] 02:47PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2152-8-24**] 02:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2152-8-23**] 04:35PM GLUCOSE-40*
[**2152-8-23**] 04:35PM UREA N-56* CREAT-2.5* SODIUM-135
POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-27 ANION GAP-18
[**2152-8-23**] 04:35PM ALT(SGPT)-18 AST(SGOT)-27 ALK PHOS-127* TOT
BILI-0.7
[**2152-8-23**] 04:35PM ALBUMIN-4.5 CALCIUM-9.1 PHOSPHATE-4.0
MAGNESIUM-2.8*
[**2152-8-23**] 04:35PM WBC-6.5# RBC-3.32* HGB-10.1*# HCT-30.4*#
MCV-92 MCH-30.4 MCHC-33.2 RDW-19.2*
[**2152-8-23**] 04:35PM NEUTS-78.1* BANDS-0 LYMPHS-15.1* MONOS-6.5
EOS-0.1 BASOS-0
[**2152-8-23**] 04:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2152-8-23**] 04:35PM PLT SMR-LOW PLT COUNT-115*#
[**2152-8-23**] 04:35PM PT-14.8* INR(PT)-1.3*
Brief Hospital Course:
The patient is a 62 y/o F hx NASH cirrhosis now s/p TIPS, with
total body overload, acute on chronic kidney disease with
worsening creatinine, and acute hypoxia requiring intubation
During her stay on the liver service, the patient's diuretic
regimen was adjusted but her ascites was felt to be refractory
and on [**8-30**] the patient underwent TIPS, which was complicated by
a small injury to the left portal vein. Despite this however,
the patient's hemoglobin remained stable. Over the next 2 days,
it was noted that the patient's creatinine had increased and
that her urine output had decreased. The patient was found to be
hypoxic to 70% on RA and was also febrile to 101.3F with a new
leukocytosis. Given her respiratory distress and hypoxia, she
was transferred to the MICU for further management.
.
In the MICU, subsequent radiographs (CXR and CT [**9-2**]) showed
moderate pulmonary edema and multifocal pneumonia with lobar
collapse. She was eventually intubated on [**9-5**] for her
progressive hypoxia and serial radiographs showed massive
pulmonary edema with superimposed multifocal pnuemonia. She was
started on vanc/zosyn/cipro. Bronchoscopy was performed and was
unrevealing. She completed an 8 day course of vanc/zosyn/cipro
but remained febrile throughout until day of d/c on [**9-12**], and by
report remained afebrile thereafter, leading to a working
diagnosis of drug fever in the context of a resolving PNA. Her
renal failure contiuned to worsen, presumably from ATN, and CVVH
was started [**9-7**] through a femoral line, mostly to take off
volume. She contiuned to require mechanical ventilation until
[**2152-9-13**], when she was successfully extubated. CXR from [**9-14**] s/p
extubation showed marked improvement in pulmonary volume
overload and pleural effusions. Was easily weaned down to 2L NC
with sats in the high 90's. Despite resolution of her hypoxia,
her renal function did not improve and she required HD on [**9-15**].
And was sent to the floor.
► CIRRHOSIS OF LIVER, OTHER - [**3-11**] NASH, stage IV disease
by biopsy. Recently s/p UGIB and banding of grade II varices.
She also developed dysphagia after EGD and variceal banding,
which has resolved. Continue ursodiol, allopurinol, rifaximin.
Nadolol no longer necessary with successful TIPS
Abdominal discomfort: Likely related to pleural effusion and abd
distention irritation of abodomen. Pt with ? L Portal vein
thrombosis on recent RUQ U/S. TIPS procedure complicated by
slight injury to L portal vein. Repeat US abd showed lack of
flow in right and left portal vein. Abdomen tympanic but with no
ascites on imaging or bedside. Recent abdominal CT shows no
evidence of obstruction. Abd pain has been resolved in recent
days.
GI against proflaxtic anticoagulation of L portal vein
thrombosis given high risk bleed. trend LFTs lack of portal vein
flow does not elimate pt as canidate for liver [**Month/Day (2) **], liver
will discuss possibity of future [**Month/Day (2) **] as team. Pt also
recently was abusing benzos. Ordered Hep panel, PPD as part of
[**Month/Day (2) **] workup. Pt will need liver [**Month/Day (2) **] eventually,
currently due to her renal fuction it is unclear whether she
will need a renal [**Month/Day (2) **] concurrently (see below).
► TIPS procedure: Occured on [**8-30**]. Pt. received a large
contrast load and was given NaHCO3 in D5W both prior to and
after the procedure. A small branch of the left portal vein was
also nicked during the procedure. Q8H hct x 3 were stable. On
[**9-1**] pt had 3 pt hct drop, complaining of RUQ pain, U/S suggests
left portal vein thrombus.
► Encephalopathy: Pt. fell OOB night of [**2064-8-25**] without
trauma; thought due to increased encephalopthy as was more
confused so lactulose increased. [**8-28**] asterixis noted &
lactulose increased again to 45 mL QID; [**8-29**] to 30 mL QID
--> pt reports she feels more alert. [**9-1**] --> increased back to
45mL QID after TIPS procedure. Currently her mental status is
signficantly improved, now she says she is at baseline, and her
Lactulose was decreased to 30ml TID. Pt should continue
lactulose and rifaximin.
► Pruitis: Pt. complaining of puritis on afternoon of [**8-31**]
and increased on [**9-1**]. Tbili is wnl, no rash, etiology unclear.
Pt. written for ranitidine 150mg [**Hospital1 **] and hydroxyzine 25mg Q6H
prn.
.
► RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **])L lobar PNA and
R pleural effusion on Chest CT from 7.25. [**9-4**] echo showed EF
>55%, Mild to moderate ([**2-9**]+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] therefore chf as cause of
volume overload/hypoxia is likely. PE/pulmonary infarct also
possible despite LENIs negative given recent TIPS placement and
possible L portal vein thrombosis. Of note the pt was not
tachycardic but was also been on nadalol. Pt hypoxia remained
resistant to increasing O2, which is more consistant with PE or
other intraparenchymal lung shunting. Pt intubated [**9-5**]. Pt
oxygenation greatly improved when vent setting switched to ARDS
settings. Extubated [**9-13**]. Temporarily desat to 85% after
extubation, however, pt rapidly requiring less oxygen, now only
on 3L NC
Believe CHF contributing to hypoxia, had restarted hydralazine
5mg q8h after extubation since also Hypertensive at that time.
However, am dose held [**3-11**] low MAP, d/ced for now in anticipation
of low BP with HD. D/c nadolol and norvasc [**3-11**] low BP
Consulted IP [**9-11**] for thoracentesis of BL plueral effusions,
however, no tapable effusion noted on US. CT Torso [**9-11**] unchanged
compared to prior.
Pt continued to spike fevers on prolonged treatment for
suspected PNA with Vanc, Zosyn, Cipro (start date 7.26), d/c
these abx [**9-13**] out of suspicion that fevers may be drug fevers.
Bronchoscopy was done [**9-12**] was concern of ongoing infection,
however, unimpressive for infection, GS just 1+ polys. Pt's
pneumonia continued to improve, and by time of dishcarge pt
continued to remain afebrile and asymptomatic and off of
antibiotics.
.
► RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)baseline
creatinine 1.3-1.7; Creatinine was initially improving this
admission, with a nadir of 1.9, then significantly worsenined
after TIPS procedure, now downtrending to 3.1. Etiology of ARF
felt be be contrast dye related as per renal. ARFrelated to
sepsis/infection or Hepatorenal syndrome being less likely. HRS
is less likely given that the patient likely has an active
infectious process and that UNa > 10. FeNa is also in the
pre-renal range. However since pt was improving on HRS meds GI
wanted to continue. No evidence of hydronephrosis on CT abdomen.
Renal believes unlikely HRS, think ATN [**3-11**] CIN. Patient was
treated for approximately 3 days with midodrine, albumin, and
octreotide with minimal effect. UO continued to decrease and
became increasingly ressistant to diuretics. CVVHD was started,
but pt required pressors for much of the treatments. CVVHD
stoped yesterday. For HD tomorrow and if tolearates HD for
tunneling line Monday. Will give Vit K on Sunday to minimize FFP
needed for line placement. Anuric at this time monitor for UO,
renal 50/50 changes of return of fxn
For transfer to floor. Pt had permanent HD catheter placed [**9-18**].
Pt's medications were changed to be renally dosed and
allopurinol was decreased to 100mg QD, and neurontin was
decreased to 200mg QD. and pt's Procrit was discontinued as
Renal would moniter this. Pt tolerated HD well, and renal
believes that she will need at least 1 mo of HD before they will
know whether pt needs HD indefinately or whether renal function
will recover. Pt will get HD three days/wk - M,W,F.
► MITRAL REGURGITATION (MITRAL INSUFFICIENCY). Pt has MR,
which might be underestimated per the echo on [**9-4**]. Had good
response to increased Hydralazine for preload and afterload
reduction, however holding to avoid hypotension with HD at this
time.
► ANEMIA, OTHER
Pt's admit hct above baseline, but trended downward on
admission. Transfused with PRBCs on [**8-27**]. Follow daily hct.
HBG now 9.1, stable, consider transfusion if clinical situation
worsen or hgb below 7.0
- on [**Hospital1 **] PPI
- no need for repeat EGD now that pt is s/p TIPS
► DIABETES MELLITUS (DM), TYPE II
difficult to control, at home on large lantus doses,
approximately 60 Lantus [**Hospital1 **]
BG more controlled, stoped TF with extubation yesterday, Insulin
gtt turned down from [**1-22**] to 5mg/hr. Restarted Glargine + HISS
on [**9-14**]
► Fever - PNA/pleural effusion related vs PE from portal
vein thrombosis. New cough since TIPS procedure. CXR/CT confirm
L lobar PNA and R sided pleural effusion.
RUQ pain s/p TIPS, but stable and not changing. No abdominal
ascites on previous imaging confirmed by bedside echo exam
therefore SBP unlikely.
Spiked again [**9-12**], pan cultured. f/u previous cultures. Pleural
tap not possible, No fluid to tap as per IP. Vanc/Zosyn/Cipro
d/ced on [**9-13**]. [**9-6**] C diff negative x 3, stoped precautions.
Source of continued fevers unclear, even after CT torso. d/c
abx, as may be drug fever. F/u Bronch results, however did not
look to be infectious.
F/u fungal cults. Pt's line was taken out [**9-21**] since pt now has
permanent HD line, but did not believe that the line was
infected.
► CAD: Known 3VD on cardiac cath in [**2151**].
- at this point ASA has been contraindictaed given GIB on ASA
- she will defer statin and ACEI at this time as per discussion
with her during last admission, she wished to discuss with her
cardiologist. I do think she would benefit from ACEI if renal
funciton returns as she hs DM, CAD and also has been having
trace proteinuria
► Seizure disorder: she has been twitching a bit, which is
her baseline. Continue keppra and lamictal at renal dose
► Anxiety: pt complains of anxiety. However h/o abusing
benzos in past
started ativan 1mg q6h prn. Will be reluctant to increase dose
much with abuse h/o
► Left wrist and shoulder pain: She has a hx of partially
torn left rotator cuff.
- plastics/hand consulted, likely a sprain, OT to fashion
splint, f/u with hand as outpt. in 2 weeks
- tylenol and oxycodone for wrist pain
- Gabapentin for neuropathic pain
► Depression: Continue celexa and seroquel
► HTN: Patient on amlodipine and nadolol at home
► Pelvic mass: Cystic structure previously identified in
LLQ.
- Pelvic ultrasound as outpatient.
Medications on Admission:
Amlodipine 5 mg daily
Allopurinol 300 mg daily
Calcium Carbonate 500 mg daily
Citalopram 40 mg daily
Folic Acid 1 mg daily
Levetiracetam 500 mg [**Hospital1 **]
Lamotrigine 100 mg QHS
Multivitamin daily
Nadolol 40 mg daily
Quetiapine 100 mg QHS
Ursodiol 500 mg [**Hospital1 **]
Rifaximin 400 mg TID
Lactulose 30 ml daily
Provigil 200 mg daily
Neurontin 300 mg TID
Lantus 65 units [**Hospital1 **] and humalog sliding scale
Furosemide 80 mg [**Hospital1 **]
Spironolactone 300 mg daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day.
17. Insulin
Continue Insulin per your previous sliding scale.
18. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
19. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for anxiety.
20. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours).
21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
22. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
23. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
End stage liver disease
Refractory Ascites from NASH cirrhosis
Acute on chronic kidney disease
.
Secondary diagnosis:
GERD
DM2 with retinopathy
Major Depression with psychosis
HTN
Retinal hemmorhage; diabetic retinopathy
Diabetic neprhopathy
OSA
Leg cramps/? RLS
DJD of neck
H/o Dermoid cyst
Right adrenal mass
Gout
CAD
Seizure d/o
Discharge Condition:
Stable, on appropriate medications
Discharge Instructions:
You were seen and evaluated for continued ascites despite taking
your diuretics. For this reason, a TIPS was performed to help
relieve the extra fluid. You are now being discharged
Please take all of your medications as directed.
Keep all of your follow-up appointments. You have been scheduled
for an ultrasound of your liver in one week. Please see
information below.
Call your doctor or go to the ED for any of the following: chest
pain, shortness of breath, fevers/chills,
nausea/vomiting/diarrhea, worsened abdominal distention or
ascites, swelling in your legs, confusion or any other symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2152-9-27**] 2:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2152-9-21**]
|
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"452",
"998.2",
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"345.90",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.1",
"33.22",
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icd9pcs
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[
[
[]
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19098, 19177
|
6179, 16786
|
344, 497
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19572, 19609
|
4159, 6156
|
20262, 20540
|
3545, 3577
|
17322, 19075
|
19198, 19198
|
16812, 17299
|
19633, 20239
|
2702, 3320
|
3592, 4140
|
274, 306
|
525, 2186
|
19335, 19551
|
19217, 19314
|
2208, 2679
|
3336, 3529
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,756
| 183,932
|
9379
|
Discharge summary
|
report
|
Admission Date: [**2144-5-2**] Discharge Date: [**2144-5-15**]
Date of Birth: [**2070-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Nausea, vomiting, hematemasis
Major Surgical or Invasive Procedure:
EGD, arteriovenous graft revision, placement of tunnelled
dialysis catheter, central line placement
History of Present Illness:
Mr. [**Known lastname 32034**] is a 74 year old man with DM II c/b triopathy, CRI
on dialysis (baseline Cr 4), aortic stenosis, dilated CMP (EF
60%), and recent GI bleed who presents with nausea, coffee
ground emesis, poor po intake, increasing confusion, and
foul-smelling urine. He was recently admitted to [**Hospital1 4494**] in [**Location (un) 1514**] for vomiting and GI bleed from
[**Date range (3) 32041**]. Workup there included EGD which showed
"narrowing, causing him to throw up" and a colonoscopy which
showed "irritation, 80%-sure irritation and not cancer" per his
son. [**Name (NI) **] his son, both EGD and colonoscopy showed a source of
bleeding, but the patient did not require any transfusions. His
son noticed that his baseline mental status decreased while
admitted, as he was more confused and unable to answer questions
about his symptoms. He was discharged, and was initially
incontinent of stool and still confused but then began to be
more active with improved appetite after a week. He still
required his son to administer medications, a task the patient
had been able to do before. Last week, his son noticed that the
patient had poor po intake, and seemed weaker with less interest
in the TV. Four days ago, his son gave the patient a suppository
and saw a bit of "fresh blood". Last night, he observed his
father vomiting; this morning, the patient had coffee ground
emesis and his urine appeared dark brown and foul-smelling. He
was brought to the ED>
In the ED, VS: T 97.9 HR 80 BP 121/52 RR 20 O2 95% RA. He was
described as endorsing chest discomfort but not true chest pain.
EKG showed diffuse T wave flattening and CXR was negative. 1st
set of cardiac enzymes showed Troponin 0.10, which was decreased
compared to prior Troponin levels and consistent with decreased
clearance [**12-28**] to his poor renal function. He was given 325 mg
ASA. To evaluate for UGI bleed, NG lavage was performed which
was negative for bleed. Guaiac was positive with brown stool. He
received 4mg Zofran IV and 40 mg pantoprazole. U/A was obtained
given his foul-smelling urine, which was positive for UTI. He
received ciprofloxacin IV 400mg. He is admitted for r/o MI,
hydration given inability to tolerate POs, w/u of GI bleed, and
UTI.
On arrival to the floor, the patient was not complaining of
nausea, vomiting, or chest discomfort. His son had stepped out.
The patient was unsure of prior chest pain, SOB, hematemesis,
foul-smelling urine, or dysuria. When his son returned, he noted
that his father normally used a walker to ambulate and had not
had any falls in the past ~9 months. He is to have follow-up on
[**2144-5-13**] with GI for the "atypical cells" found on the
colonoscopy.
Past Medical History:
Type I diabetes mellitus, dx in [**2105**] complicated by:
- peripheral neuropathy
- retinopathy
- nephropathy
Hypertension
Aortic Stenosis
Chronic renal insufficiency
Spinal spondylosis
Idiopathic dilated cardiomyopathy
BPH
Compression fracture C4-5
Bone cancer in childhood
Social History:
Mr. [**Known lastname 32034**] lives with his son and his son??????s wife and daughter
in [**Name (NI) **]. His son has been very involved in his care since
[**2139**]. He has another son, two biological daughters and an
adopted daughter. His wife passed away 10yrs ago. He is a
retired police officer. He has a 60 pack-year smoking hx, but
quit many years ago. He used to drink ~8 drinks/day, but also
quit some time ago and neither smokes or drinks anymore.
Family History:
Noncontributory
Physical Exam:
VS: T: 98.0 HR: 80 BP: 130/70 RR: 20 Sat: 91% RA
Gen: Pleasant, appears stated age, well-nourished, NAD, NG tube
in place.
Skin: pink, no rashes, no suspicious lesions, no jaundice
HEENT: NCAT. PERRL, EOMI, sclerae anicteric. Dry MM, normal
dentition.
Neck: Supple, no lymphadenopathy, JVP flat. Carotid upstrokes
are brisk without bruits.
CV: RRR, nl S1, S2. III/VI crescendo-decrescendo murmur best
heard at base with radiation to the carotids and abdomen. No
rubs or gallops.
Resp: CTAB. No rales, rhonchi or wheezes.
Abd: Well-healed vertical scar on RUQ. +BS, soft, NT/ND, no HSM,
no rebound or guarding.
Back: No CVA tenderness.
Rectal: Guaiac: Positive in ED
Ext: Warm, well-perfused, no C/C/E. DP 2+ bilaterally.
Neuro: Alert and oriented to person and "hospital" but not date.
Cranial nerves II-XII intact. No gross focal deficits.
Pertinent Results:
[**2144-5-2**] 09:50AM BLOOD WBC-9.1 RBC-3.49* Hgb-10.0* Hct-31.4*
MCV-90 MCH-28.8 MCHC-32.0 RDW-14.0 Plt Ct-223
[**2144-5-5**] 07:00AM BLOOD WBC-8.6 RBC-3.75* Hgb-11.2* Hct-33.4*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.0 Plt Ct-221
[**2144-5-11**] 06:55AM BLOOD WBC-7.9 RBC-3.87* Hgb-11.4* Hct-34.1*
MCV-88 MCH-29.4 MCHC-33.4 RDW-15.5 Plt Ct-177
[**2144-5-12**] 09:15AM BLOOD WBC-12.7*# RBC-4.01* Hgb-11.6* Hct-36.0*
MCV-90 MCH-28.8 MCHC-32.1 RDW-15.4 Plt Ct-164
[**2144-5-13**] 02:10PM BLOOD WBC-17.0* RBC-3.34* Hgb-9.7* Hct-29.7*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.2 Plt Ct-130*
[**2144-5-15**] 05:35AM BLOOD WBC-15.1* RBC-3.27* Hgb-9.6* Hct-29.4*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.0 Plt Ct-148*
[**2144-5-2**] 09:50AM BLOOD Neuts-81.7* Lymphs-12.0* Monos-4.9
Eos-0.9 Baso-0.5
[**2144-5-15**] 05:35AM BLOOD Neuts-91.6* Lymphs-5.3* Monos-2.9 Eos-0.2
Baso-0
.
[**2144-5-2**] 09:50AM BLOOD PT-13.6* PTT-23.1 INR(PT)-1.2*
[**2144-5-3**] 02:55AM BLOOD PT-14.0* PTT-23.9 INR(PT)-1.2*
[**2144-5-11**] 06:55AM BLOOD PT-13.0 PTT-25.2 INR(PT)-1.1
.
[**2144-5-2**] 09:50AM BLOOD Glucose-221* UreaN-23* Creat-4.1* Na-140
K-4.7 Cl-92* HCO3-36* AnGap-17
[**2144-5-6**] 07:45AM BLOOD Glucose-174* UreaN-33* Creat-6.6*# Na-142
K-3.5 Cl-92* HCO3-35* AnGap-19
[**2144-5-11**] 06:55AM BLOOD Glucose-319* UreaN-42* Creat-7.0* Na-135
K-4.2 Cl-93* HCO3-25 AnGap-21*
[**2144-5-14**] 06:58AM BLOOD Glucose-333* UreaN-42* Creat-6.4*# Na-136
K-4.0 Cl-97 HCO3-27 AnGap-16
[**2144-5-15**] 05:35AM BLOOD Glucose-181* UreaN-28* Creat-4.3*# Na-139
K-3.7 Cl-103 HCO3-30 AnGap-10
[**2144-5-2**] 07:00PM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.0 Mg-1.6
[**2144-5-6**] 07:45AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.9
[**2144-5-10**] 06:55AM BLOOD TotProt-5.8* Calcium-8.2* Phos-3.4 Mg-2.2
[**2144-5-15**] 05:35AM BLOOD Calcium-7.9* Phos-1.5*# Mg-1.8
.
[**2144-5-2**] 07:00PM BLOOD ALT-15 AST-26 LD(LDH)-236 CK(CPK)-96
AlkPhos-86 Amylase-28 TotBili-0.6
[**2144-5-8**] 03:42AM BLOOD ALT-11 AST-16 AlkPhos-83 TotBili-0.5
[**2144-5-2**] 07:00PM BLOOD Lipase-16
[**2144-5-7**] 08:05AM BLOOD Lipase-18
.
[**2144-5-2**] 09:50AM BLOOD CK-MB-4 cTropnT-0.10*
[**2144-5-2**] 07:00PM BLOOD CK-MB-3 cTropnT-0.09*
[**2144-5-3**] 02:55AM BLOOD CK-MB-NotDone cTropnT-0.11*
.
[**2144-5-2**] 07:00PM BLOOD VitB12-1756* Folate-GREATER TH
[**2144-5-14**] 07:30PM BLOOD calTIBC-103* Ferritn-1280* TRF-79*
[**2144-5-15**] 05:35AM BLOOD Triglyc-57
[**2144-5-2**] 07:00PM BLOOD TSH-7.5*
[**2144-5-3**] 02:55AM BLOOD Free T4-0.93
.
CXR [**5-3**]
CHEST, THREE VIEWS: There has been interval placement of an OG
tube with tip
and side hole projecting below the diaphragm. The heart size is
top normal
and unchanged as are mediastinal and hilar contours. There is no
pneumothorax
or pleural effusion. Right superior mediastinal fullness likely
relates to
tortuous vessels. No airspace opacification identified. The
pulmonary
vasculature is normal. No gross osseous abnormality.
IMPRESSION: No acute cardiopulmonary process.
.
Head CT [**5-3**]
FINDINGS: The ventricles and sulci are prominent consistent with
age-
appropriate atrophy. Periventricular white matter hypodensities
are noted,
consistent with chronic small vessel ischemic changes. There is
no shift of
normally midline structures. Calcifications of the carotid
arteries are
noted. The visualized paranasal sinuses are clear. There is no
evidence of
hemorrhage.
IMPRESSION: No evidence of hemorrhage or shift of normally
midline
structures. Chronic small vessel ischemic changes.
.
KUB [**5-5**]
ABDOMEN, TWO VIEWS: Nonspecific bowel gas pattern with stool and
gas seen in
the large bowel. Interval verteboplasty. There is an anterior
fixation
device at L5-S1. Otherwise, no gross osseous abnormality. There
is linear
atelectasis versus scarring at the left lung base. Phleboliths
are seen in the
pelvis.
IMPRESSION: No radiographic evidence for obstruction.
.
[**5-5**] BARIUM UPPER GI STUDY
The study was limited due to patient factors and aspiration.
Barium passes
freely through the esophagus into the stomach, and there is no
demonstration
of mucosal abnormality or stricture. In the 50 minutes of the
exam, barium
did not pass into the small bowel. Barium is seen in the
tracheal tree
secondary to regurgitation and aspiration. Limited views of the
stomach do
not demonstrate a mucosal abnormality. There is an anterior
fixation device,
and there has been a vertebroplasty.
IMPRESSION: No transit of barium from the stomach: gastroparesis
versus
gastric outlet obstruction; recommend nuclear medicine gastric
emptying study.
.
CT abd/pelvis [**5-8**]
IMPRESSIONS:
1. Contrast material has progressed to the colon, indicating the
absence of a complete obstruction. However, the large amount of
retained barium in the stomach reflects a significant delay in
gastric emptying. Diagnostic
considerations include severe gastroparesis or partial gastric
outlet
obstruction.
2. Possible precipitation of retained barium in the stomach,
with refluxed
contrast material in the esophagus. Nasogastric suctioning is
recommended.
3. Moderate ascites.
4. Small layering gallstones.
5. Extensive atherosclerotic calcification of coronary arteries,
aorta and
major branches.
6. Aspirated barium at the right lung base.
7. Upper lumbar vertebroplasty with retropulsed fragment of L2
into the
spinal canal.
.
UE Doppler [**5-11**]
FINDINGS: There is thrombus located within one of the patient's
brachial
veins as well as the basilic vein. There is no evidence of
thrombus within
internal jugular, subclavian, or axillary veins in which
compressibility,
flow, and augmentation is maintained throughout. These findings
are discussed with Dr. [**First Name (STitle) **] at the time of dictation.
IMPRESSION:
1. Thrombus identified within brachial and basilic veins as
noted.
.
[**5-14**] CXR
Right internal jugular vascular catheter is unchanged in
position, but new
right internal jugular dialysis catheter has been placed, with
tip terminating
in expected location of proximal right atrium. No pneumothorax.
Moderate
right pleural effusion has slightly increased in size, with
adjacent
increasing consolidation at right lung base. Small left pleural
effusion is
also evident as well as minor atelectasis at the left base.
High-density
material is present adjacent to the right hemidiaphragm, likely
due to
aspirated barium, as reported on earlier radiograph of [**2144-5-7**].
Deformity of proximal left humerus is likely due to old injury.
IMPRESSION:
1. Increasing right effusion and adjacent right basilar
consolidation. The
latter may potentially be due to an evolving infection, possibly
secondary to
aspiration.
2. Small left pleural effusion.
Brief Hospital Course:
74 year old man with DM II c/b triopathy, CRI on dialysis
(baseline Cr 4), aortic stenosis, dilated CMP (EF 60%), and
recent GI bleed who presents with nausea, coffee ground emesis,
poor po intake, increasing confusion, UTI, and ?chest
discomfort. Briefly, pt was being treated for upper GI bleed and
suspected severe gastroparesis when he missed an oral dose of
amiodarone and went into rapid ventricular rate atrial
fibrillation. He was then transferred to the CCU, where he was
placed on an amiodarone drip until rate controlled. He was
subsequently transferred back to the floor on PO amiodarone.
Please see below for a summary of [**Hospital **] hospital course by
problem:
.
*) Nausea/coffee ground emesis, with poor po intake: Pt had hx
of severe gastroparesis with admissions for similar sx in the
past. He had an EGD on HD#2 which revealed a medium hiatal
hernia, tortuous esophagus, erythema with single
polyp/protrusion at the gastroesophageal junction, [**Doctor First Name **]-[**Doctor Last Name **]
tear, edematous antral folds, edematous duodenal mucosa, and a
polyp in the stomach body. On HD#[**2-29**], pt began to have
significant emesis and had an upper GI series, which
demonstrated contrast in the stomach for >24hrs, consistent with
prolonged gastric transit secondary to severe gastroparesis vs.
obstruction. Abdominal CT revealed contrast in the colon, ruling
out complete obstruction, but differentiating between
gastroparesis and partial gastric outlet obstruction was not
possible with that exam. Reglan did not lead to any improvement.
An NGT was placed, but pt self-d/c'd on HD#9. Pt was started on
erythromycin with some improvement in vomiting, but this was
d/c'd as pt's QT became more prolonged. Given lack of
improvement, concern for process other than gastroparesis was
considered and repeat EGD to further evaluate previously seen
gastric/duodenal pathology. Prior to this study, pt began to
have significant bilious emesis. NGT was placed and again d/c'd
by pt. EGD was postponed secondary to medical instability. GI
recommended restarting reglan and continued to follow pt. TPN
was also started on HD#13.
.
*) GI bleed: Pt was recently discharged from [**Hospital3 3765**]
([**4-19**]) after admission for GI bleed. He had an endoscopy and
colonoscopy at that hospital which showed prepyloric antritis
consistent with gastroparesis, esphagitis with mucosal
ulceration, moderate-severe ischemic colitis, sigmoid
diverticulitis, and internal hemorrhoids. In the first 24 hrs of
admission, pt's hct decreased from 31->25, where it stabilized
and then trended upwards throughout the rest of the admission.
He had an EGD with results as above.
.
*) Atrial fibrillation: Hx of a fib, not currently
anticoagulated secondary to GI bleed. Pt with significant
emesis, missed one dose of PO amiodarone and was found to be in
asymptomatic rapid a fib on HD#6. He was transferred to the CCU,
where he was quickly stabilized on amio drip then transitioned
back to PO. He was then transferred back to the floor on HD#7,
where he remained in rate controlled sinus rhythm until HD#14,
when he had an episode of a fib with RVR which was responsive to
10mg IV metoprolol. A few hours later, he returned to this
irregular rhythm, which was then unresponsive to 10mg metoprolol
and 30mg diltiazem, with resultant hypotension. Given his
cardiac instability, he was transferred to the MICU for further
care.
.
*) ESRD: Pt with R AVF in place for M/W/F HD. On HD#10, pt
unable to be dialyzed secondary to clotted fistula. He was
evaluated by transplant surgery and taken to the OR on HD#11 for
revision of the fistula, which subsequently re-thrombosed in
dialysis that day. A tunnelled catheter was then placed for
continued dialysis. His medications were renally dosed while in
house.
.
*) L upper extremity DVT: On HD#10, pt's left arm (site of
peripheral IV) was noted to be edematous. He had a doppler study
which revealed DVTs in the basilic and brachial veins. He was
started on a heparin gtt on HD#13, as the risk of
hypercoaguability was determined to outweigh the risk of further
GI bleed.
.
*) ?Chest discomfort: No specific EKG changes to suggest
ischemia; patient has no h/o CAD. Received ASA in ED. Repeat EKG
with no change. Three sets of cardiac enzymes were stable, not
indicative of ACS. Pt did not have any further sx during this
admission.
.
# DM II: Pt was on lantus and ISS at home. His lantus dose was
decreased given poor PO intake. With the addition of intravenous
nutrition, his blood glucose increased and dosages of insulin
were appropriately adjusted. Blood glucose was frequently
elevated likely secondary to variable absorption of intake.
.
*) Delirium: Per son, likely developed during hospitalization at
[**Hospital1 **] in mid-[**Month (only) 116**]; pt has not returned to baseline since. Used
to dress himself, take his own meds, no memory deficits that son
is aware of - could recall conversations and events from days,
weeks, years ago. Pt with flat affect, poor short term memory,
and apparent cognitive deficits on this admission. Head CT was
normal. Sx felt to be secondary to dementia, environment, and
worsening renal failure.
.
*) UTI: Pt makes very little urine at baseline. U/A showed [**10-15**]
WBC, nitrite negative, rare bacteria. Pt was started on
ceftriaxone, but urine cx negative so abx d/c'd.
.
*) HTN/idiopathic cardiomyopathy/aortic stenosis: Last EF from
[**11-1**] 60%. Pt has known moderate aortic stenosis. ASA 81 mg held
due to concern for GI bleed. Amiodarone, metoprolol, and
atorvastatin were continued.
.
*) Hypothyroidism: Pt had elevated TSH, thought to be secondary
to decreased absorption of levothyroxine in setting of prolonged
gastric emptying. Levothyroxine dose was increased and changed
to IV in setting of poor tolerance of POs.
.
*) FEN: Pt NPO for first few days of admission. As emesis
resolved, he was able to take sips of liquids, but still had
poor PO intake. Nutrition recommended tube feeds, but pt
declined. He was started on PPN, which was subsequently d/c'd
out of concern for poor renal function. After dialysis was
reiintiated, TPN was started.
.
Pt was transferred to the MICU on HD#14. After extensive
discussion with the family upon arrival to the MICU, the
decision was made to discharge the patient to home with hospice
care.
Medications on Admission:
AMIODARONE 200 mg--1 tablet(s) by mouth daily
ASPIRIN 81 mg--1 tablet(s) by mouth once a day
COREG 12.5 mg--1 tablet(s) by mouth twice a day
Citalopram 40 mg--1 (one) tablet(s) by mouth at bedtime
DOCUSATE SODIUM 100 mg--1 capsule(s) by mouth daily
EPOGEN 4,000 unit/mL--8,000 units by hemodialysis mon, wed, fri
Fludrocortisone 0.1 mg--1 tablet(s) by mouth daily at noon
HUMALOG 100 unit/mL--sliding scale at breakfast, lunch,dinner.
no added insulin for bedtime
LANTUS 100 unit/mL--30 units q morning
LIPITOR 40 mg--1 tablet(s) by mouth daily
Levothyroxine 25 mcg--1 (one) tablet(s) by mouth once a day
MULTIVITAMIN --1 tablet(s) by mouth once a day
NEPHROCAPS 1 mg--1 capsule(s) by mouth daily
SENNA 8.6 mg--1 tablet(s) by mouth daily
B complex-C-folic acid 1 mg by mouth daily
Protonix
Carafate
Metoclopramide
Discharge Medications:
1. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 0.25-0.5 mL
PO q2h:prn as needed for shortness of breath or wheezing for 1
weeks: goal comfort .
Disp:*30 ml* Refills:*2*
2. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) PO
q2h:prn for 1 weeks.
Disp:*30 mL* Refills:*0*
3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours for 1 weeks: if needed for
secretions.
Disp:*5 * Refills:*2*
4. Acetaminophen 325 mg Suppository Sig: One (1) Rectal every
four (4) hours for 1 weeks.
Disp:*30 * Refills:*2*
5. Prochlorperazine 25 mg Suppository Sig: One (1) Rectal every
four (4) hours as needed for nausea for 1 weeks.
Disp:*20 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice
Discharge Diagnosis:
Primary:
Hematemesis due to [**Doctor First Name **]-[**Doctor Last Name **] tear/Gastritis/Esophagitis
Delirium
A fib
ESRD
Severe gastroparesis
DVT x 2
Secondary:
Diabetes Type I with triopathy
HTN
Idiopathic dilated CMP
Aortic stenosis
Hyperlipidemia
Renal insufficiency requiring dialysis
BPH
Compression fractures of spine
Spinal stenosis
Discharge Condition:
Comfortable
Discharge Instructions:
You were admitted with bloody vomiting and found to have some
inflammation of your stomach lining and esophagus. After family
discussion we are planning on discharging you home with comfort
measures.
[**Doctor First Name 16883**] from [**Hospital 269**] Hospice care phone [**Telephone/Fax (1) 32042**] (fax
[**Telephone/Fax (1) 32043**]) will come assist you at home this evening. If you
have any questions overnight please call the critical care unit
at [**Telephone/Fax (1) 250**] or Dr.[**Name (NI) 1602**] office for assistnace.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 713**] [**Telephone/Fax (1) 719**] as needed.
|
[
"362.01",
"427.31",
"428.0",
"733.13",
"272.4",
"599.0",
"V10.82",
"211.1",
"250.50",
"453.8",
"V15.82",
"996.73",
"536.3",
"V45.1",
"424.1",
"403.91",
"276.51",
"250.60",
"244.9",
"380.4",
"250.40",
"535.50",
"600.00",
"294.8",
"585.6",
"425.4",
"553.3",
"458.9",
"V58.67",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"39.95",
"88.67",
"38.95",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
19442, 19499
|
11528, 17865
|
343, 445
|
19887, 19901
|
4873, 11505
|
20486, 20583
|
3978, 3995
|
18733, 19419
|
19520, 19866
|
17891, 18708
|
19925, 20463
|
4011, 4854
|
274, 305
|
473, 3185
|
3207, 3484
|
3500, 3962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,032
| 164,401
|
23331
|
Discharge summary
|
report
|
Admission Date: [**2139-11-20**] Discharge Date: [**2139-11-27**]
Date of Birth: [**2083-6-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
1. pericardiocentesis with pericardial window
2. transesophageal echocardiogram
History of Present Illness:
56y/o M with history of hypertension presented to [**Hospital1 3325**] with chest pain and shortness of breath. Pain radiated
to back. Pt underwent CTA, which showed a large pericardial
effusion, and pt was transferred to [**Hospital1 18**] for emergent
pericardiocentesis. Pt was hypotensive at 89/64 in the ED and
was taken for emergent pericardiocentesis. TTE demonstrated
tamponade physiology with RV collapse; about 1 liter of fluid
was removed, with reversal of tamponade physiology seen on TEE.
Pt denied chest pain per se, but did complain of indigestion.
Noted increasing dyspnea over the day prior to admission.
Denied PND or orthopnea. No fevers, chills, night sweats.
Reports losing about 25 lbs in the last 2 years, but says that
he has decreased his beer intake. No known TB exposures.
Past Medical History:
1. hypertension
2. chronic lower back pain
3. s/p appendectomy at 8 y/o
4. s/p tympanoplasty
Social History:
Pt worked construction - developed lower back pain worse with
working; did not seek medical attention; is now on disability
due to back pain. Tobacco: about 1 [**12-5**] ppd x 36 yrs. EtOH:
Drank about 18 beers a day, for about 36 years, but has had only
4-5 beers in last month. Smokes marijuana occasionally, last
joint about 3-4 weeks ago. Lives with partner [**Name (NI) **], whom he
has had a relationship with for the last 30 years. No children
with her, though she has a 37y/o son who lives in CA.
Family History:
noncontributory
Physical Exam:
On admission:
VS: 97/77 110 18 100% NRB
Gen: A&O x3
HEENT: PERRL, EOMI, supple neck, OP clear
Neck: bilateral JVD (not documented how high)
Pulm: CTAB, no crackles but coarse breath sounds
CV: RRR, nl S1/S2, distant
Abd: soft, NT/ND, +BS
Ext: dusky feet, [**2-5**] s cap refill
VS: Tm 98.8 Tc 98.8 120/70 (110s-130s/60s-80s) 101 (80s-110s)
17 95% 5L NC
I/O 1657/1050 (18h)
Gen: NAD, pleasant, no respiratory distress
HEENT: OP clear, edentulous, MMM, PERRL, EOMI; R tympanic
membrane - will examine further in AM, but no visible draining
fluid at this time
Pulm: CTAB, though lungs sounds somewhat decreased, no
crackles, mild dullness at bases
CV: RRR, nl S1/S2, no murmurs appreciated
Neck: no JVD
Abd: soft, NT/ND, +BS, no masses
Ext: no edema, no calf tenderness
Pertinent Results:
outside films reviewed by [**Hospital1 18**] radiology:
- hilar/mediastinal LNs, mostly R sided, no lung masses
- fibrosis/emphysema
- adrenals normal
- nodes mostly consistent with SCLC versus lymphoma vs mets vs
TB
- hiatal hernia
[**2139-11-23**] pericardial fluid (from chest tube): ATYPICAL. Highly
atypical mesothelial cells present, favor reactive. Cytology
for malignant cells negative.
[**2139-11-23**] pathology of pericardial window:
Pericardium with chronic inflammation, reactive mesothelial
cells, and focal atypical cellular aggregates; reactive changes
are favored.
No vasculitis, granulomas, or atypical lymphoid infiltrate
identified.
[**2139-11-24**] CTA:
1. Predominantly left lower lobe pulmonary embolus, with
thrombus filling the left lower lobe superior segment pulmonary
artery and extending into the left lower lobe basilar pulmonary
artery. A less significant amount of thrombus is probably also
be present within the right upper lobe pulmonary arteries.
2. Bulky right hilar lymphadenopathy, with other enlarged
mediastinal and left hilar lymph nodes.
3. Trace pericardial effusion and a small right-sided pleural
effusion.
4. No discrete pulmonary masses are seen.
5. Bilateral lower lobe atelectasis.
6. Emphysema.
[**2139-11-26**] bilateral LE ultrasound: no evidence of DVT.
[**2139-11-26**] transthoracic echo: The left atrium is normal in size.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Left ventricular systolic
function appears grossly preserved but was not adequately
assessed. Right ventricular chamber size appears normal with
preserved free wall motion. The aortic root is moderately
dilated. The aortic valve is not well seen. The mitral valve is
not well seen. There is no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2139-11-20**], the
pericardial effusion is now gone.
Micro data:
[**2139-11-21**] ear fluid: RESPIRATORY CULTURE (Final [**2139-11-23**]):
PROTEUS MIRABILIS. HEAVY GROWTH.
Trimethoprim/Sulfa sensitivity available on request.
ALPHA STREPTOCOCCI. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
FUNGAL CULTURE (Final [**2139-12-7**]): NO FUNGUS ISOLATED.
[**2139-11-20**] pericardial fluid: no growth
pericardial tissue: no growth
[**2139-11-20**] blood cultures negative
12/1704, [**2139-11-22**], [**2139-11-27**] urine culture no growth
Admission labs:
[**2139-11-20**] 10:43AM GLUCOSE-134* NA+-128* K+-3.2* CL--96* TCO2-25
[**2139-11-20**] 10:37AM UREA N-32* CREAT-1.3*
[**2139-11-20**] 10:37AM ALT(SGPT)-16 AST(SGOT)-12 CK(CPK)-23* ALK
PHOS-55 AMYLASE-21 TOT BILI-0.4
[**2139-11-20**] 10:37AM LIPASE-18
[**2139-11-20**] 10:37AM CK-MB-NotDone cTropnT-<0.01
[**2139-11-20**] 10:37AM ALBUMIN-3.2* CALCIUM-7.4* PHOSPHATE-3.1
MAGNESIUM-1.7 URIC ACID-8.2*
[**2139-11-20**] 10:37AM TSH-0.71
[**2139-11-20**] 10:37AM CORTISOL-34.3*
[**2139-11-20**] 10:37AM WBC-17.3* RBC-3.74* HGB-11.6* HCT-31.9*
MCV-85 MCH-31.0 MCHC-36.3* RDW-12.3
[**2139-11-20**] 10:37AM NEUTS-88.8* LYMPHS-6.4* MONOS-3.9 EOS-0.8
BASOS-0.1
[**2139-11-20**] 10:37AM PT-14.0* PTT-28.0 INR(PT)-1.2
[**2139-11-20**] 10:37AM PLT COUNT-383
[**2139-11-20**] 01:45PM [**Doctor First Name **]-POSITIVE TITER-1:320
[**2139-11-20**] 01:45PM RHEU FACT-14
[**2139-11-20**] 01:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-11-20**] 01:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-11-20**] 01:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
Discharge labs:
Hct 37.2
sodium 133
BUN 10
Cr 0.5
Mg 1.8
Brief Hospital Course:
1. pericardial effusion - Pt was initially taken emergently for
pericardiocentesis as he was hypotensive with pericardial
tamponade physiology with right ventricular collapse. He was
placed transiently on a dopamine drip to maintain blood
pressure. He was intubated and brought to the OR, where
pericardiocentesis and creation of a pericardial window were
undertaken. Close to 1 L of bloody pericardial fluid was
removed, and L pleural and pericardial drainage tubes were
placed. Repeat echo showed resolution of tamponade physiology,
and pt was transferred to the CCU. Dopamine drip was weaned, pt
was extubated, and pt recovered well with no further
reaccumulation of fluid. The last drain was removed on [**11-23**].
Pt was transferred to the floor. His blood pressure remained
stable and he showed no clinical evidence or symptomatology
indicative of reaccumulation of pericardial fluid. A repeat
echocardiogram on [**11-26**] showed no interval reaccumulation of
pericardial fluid. Attention was turned to diagnosing the
underlying condition causing pt's pericardial effusion.
Malignancy was high on the differential diagnosis, as well as
rheumatologic conditions and infection such as tuberculosis.
Pulmonary consult was called. Pathology of the pericardial
window showed no granulomas and no evidence of malignancy;
simply reactive mesothelial cells. Given the concomitant
presence of a pulmonary embolus (see below) and lymphadenopathy
on CT, a tissue diagnosis is necessary. Surgery was consulted
to evaluate whether a peripheral lymph node could be biopsied at
the bedside, but it seemed that these lymph nodes were likely
not to be pathologic based on exam. Further review of the films
with pulmonary team suggested that a mediastinoscopy would be
the best procedure to obtain a tissue diagnosis. Pt desired
strongly to go home for the holidays, and followup was arranged
carefully for pt to go to the cardiothoracic surgery clinic to
see Dr. [**Last Name (STitle) 952**] 2 days after discharge, for a likely elective
mediastinoscopy later in the week, with pulmonary followup
afterwards.
2. pulmonary embolism - Pt was transiently hypoxic in the first
2 days of admission, and he complained of back pain. He also
had sinus tachycardia. A pulmonary embolus was found on CT
angiogram, predominantly in the left lower lobe but possibly
also in the right upper lobe. Pt was placed on a heparin drip
and had no further complication, with good oxygen saturation.
He was discharged on lovenox, which will be stopped prior to his
mediastinoscopy. The initiation of coumadin was deferred until
after pt's definitive procedure for tissue diagnosis, and he
will follow up as an outpatient for management of his coumadin.
The presence of both PE and pericardial effusion placed
malignancy higher on the differential.
3. Proteus mirabilis otitis externa - Pt had noted progressive
hearing loss over the last few months and has a history of a
perforated tympanic membrane. His ears were draining fluid,
particularly the right ear. This fluid was sent for culture and
grew out Proteus mirabilis, which was pansensitive. ENT was
curbsided, and ciprofloxacin drops were recommended, as well as
po Augmentin, both for 10 day course. Pt will follow up with
ENT as an outpatient to monitor clinical progress.
4. hyponatremia - Pt's sodium remained stable, on the low side
of 131-133 for the majority of his hospitalization. Concern was
for SIADH in the setting of probable malignancy in his clinical
context. Pt was placed on fluid restriction and was advised to
continue this at home.
5. back pain - this was a chronic issue, musculoskeletal in
nature. Pt was placed on oxycodone and tylenol for control of
back pain.
6. hypertension - Pt was continued on his ACE inhibitor. His
hydrochlorothiazide was held in the hospital and then was
restarted at discharge. Pt also started on Toprol XL with good
BP control.
7. FEN/GI - Pt was placed on a cardiac/heart healthy diet on
transfer to the floor, with fluid restriction due to
hyponatremia. His other electrolytes remained stable.
8. hematuria - pt was noted to have lg blood on his UA on the
day of discharge from the hospital; this should be followed up
as an outpatient. No further workup was done during his
hospital stay as he was hemodynamically stable with a normal
hematocrit.
9. Code - full
Medications on Admission:
hydrochlorothiazide 25mg po daily
lisinopril 20mg po daily
ibuprofen 600mg
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Enoxaparin Sodium 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 25 days.
Disp:*50 injection* Refills:*0*
7. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic TID
(3 times a day) for 8 days.
Disp:*1 bottle* Refills:*0*
8. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) patch
Transdermal once a day for 4 weeks.
Disp:*28 patches* Refills:*0*
9. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) patch
Transdermal once a day for 2 weeks: use these patches after you
are finished with the 21 mg patches.
Disp:*14 patches* Refills:*0*
10. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) patch
Transdermal once a day for 2 weeks: use these after you have
completed the 14mg patches.
Disp:*14 patches* Refills:*0*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. pericardial effusion, with tamponade, status post
pericardial window
2. pulmonary embolus
3. otitis externa with pansensitive Proteus mirabilis
4. lymphadenopathy
Secondary:
1. hypertension
2. tobacco dependence
3. hematuria
Discharge Condition:
stable, no pericardial effusion on repeat echo, no chest pain or
SOB, ambulating, tolerating po
Discharge Instructions:
If you notice shortness of breath or chest pain, come to the
emergency room. Please take all of your medications as
prescribed. If you notice any blood in your stool,
maroon-colored stool, or if you have bloody vomiting, please
come to the emergency room.
You will need to come back next week for a mediastinoscopy to
get a biopsy of your lymph nodes. At 9AM on Monday, please call
Dr.[**Name (NI) 1816**] office at ([**Telephone/Fax (1) 1504**]. You will see Dr. [**Last Name (STitle) 952**]
on Monday, and then you will return a few days later for your
mediastinoscopy. Tell them that Dr. [**Last Name (STitle) 952**] said that you need
to see him on Monday.
You will need to give yourself Lovenox shots twice a day to keep
your blood thin. On the morning that you come in for the
mediastinoscopy, do not give yourself a shot. Dr. [**Last Name (STitle) 952**] will
tell you when you should restart the Lovenox.
After the mediastinoscopy, you will need to have coumadin begun
to treat your pulmonary embolus (clot in the lung). You will
need to be followed in coumadin clinic to have your blood drawn
to make sure that you are on the correct dose. More specific
instructions will follow.
You have an ear infection, for which you are being treated with
amoxicillin/clavulanate (a pill) and ear drops. You should
follow up with an ENT doctor for this, as below. Please call to
make an appointment.
Followup Instructions:
1. On Monday, at 9AM, call Dr.[**Name (NI) 1816**] office at ([**Telephone/Fax (1) 1504**]
to make an appointment to see him on the same day. He is the
cardiothoracic surgeon who will be doing your mediastinoscopy.
2. Please call ([**Telephone/Fax (1) 1300**] to make an appointment to see Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5600**] in 2 weeks (first week of [**Month (only) 404**]), who will be
your primary care doctor at least until this is all sorted out.
3. Please call the pulmonary clinic, at (617) 667-LUNG (([**Telephone/Fax (1) 514**]) to make an appointment to see any of the pulmonary
doctors sometime in the second week of [**Month (only) 404**]. They will tell
you the results of the biopsy.
4. You should call to make an appointment to see an ENT doctor
for your ear infection: ([**Telephone/Fax (1) 6213**]. You have a perforated
tympanic membrane and the fluid draining from your ear is
infected.
|
[
"305.1",
"380.10",
"276.1",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"88.72",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
13098, 13104
|
7121, 11511
|
351, 435
|
13392, 13489
|
2773, 5842
|
14950, 15908
|
1935, 1952
|
11637, 13075
|
13125, 13371
|
11537, 11614
|
13513, 14927
|
7056, 7098
|
1967, 1967
|
277, 313
|
463, 1272
|
5858, 7040
|
1981, 2754
|
1294, 1392
|
1408, 1919
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,174
| 105,537
|
28409
|
Discharge summary
|
report
|
Admission Date: [**2118-10-30**] Discharge Date: [**2118-11-25**]
Date of Birth: [**2072-7-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Fever, pancytopenia, RUQ pain.
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
ERCP with CBD stent placement
Central Line/HD Line placement
Intubation
Lumbar Puncture
Bronchoscopy
History of Present Illness:
HPI: 46 yo M with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2905**] [**Last Name (un) **] s/p thymectomy on Imuran
who initially presented to his PCP [**Name Initial (PRE) 151**] T103 and dry cough
treated with Amoxicillin and Augmentin without improvement. He
was then admitted to an OSH on [**2118-10-25**] for pancytopenia (WBC
2.6, 18% bands, plt 104) and elevated LFTS c/w cholestasis. He
was treated with Azythromycin and Atovaquone for suspected tick
borne illness. He had a positive monospot test. Hepatitis
serologies were negative.
.
Patient was admitted to the surgical service at [**Hospital1 18**] on
[**2118-10-30**] for persisitent fever and an elevated direct Tbili
thought to be secondary to cholangitis. He was started on
Unasyn. He underwent an ERCP on [**10-31**] which did not show
biliary tract obstruction, however, a CBD stent was placed. He
was transfused 1 Unit of PRBC's, 3 bags of FFP, and 3 bags of
plts.
.
Prior to the ERCP he developed repsiratory distress and was
intubated. CXR revealed bilateral patchy pulmonary infiltrates.
He became hemodynamically unstable and he was started on Norepi
gtt. ID was consulted and Ceftriaxone/ Doxycyclin were added;
Zosyn was d/c'ed. He spiked a temp to 105.3. He was transfered
to the MICU on [**10-31**] for further managament.
Past Medical History:
- Myasthenia [**Last Name (un) 2902**] for 19 years s/p thymectomy [**2103**]
- Migraines
- Prednisone induced osteoporosis
- Low back Pain
Social History:
Has a girlfriend. [**Name (NI) **] a 14 yo son who recently had a cold.
Lives with girlfirend and step children. Smokes and drinks EtOH
occassionally. No hx of IVDU. Lives in [**Location 4310**] near a swamp.
Breakheart reservation is 2 miles away. No hx of tick bites.
Family History:
Mother has HTN.
Physical Exam:
Upon transfer to [**Hospital Unit Name 153**]:
Tm 102.2 Tc 97.6 BP 175/92 (108-175/52-92) HR 89 (71-111)
PS 5/0 FiO2 35% Vt 850 (700-850) RR 16; ABG 7.44/33/173/23
Fentanyl 125; Off Midaz since [**11-6**]
Gen: Sedated/intubated, appears comfortable on ventilator,
occasional hiccups
HEENT: ET tube in place, Eyes with lubricant, PERRL, pupils
pinpoint
CV: distant heart sounds. No murmurs appreciated.
Resp: anteriorly - crackles throughout
Abd: Soft, distended, decreased BM, unable to appreciate HSM
Skin: Warm. Well Perfused.
Ext: hyperreflexic, Spastic, 5 beats of myoclonus, Toes
upgoing, strong DP/PT pulses
Access: Right IJ triple lumen placed [**11-6**], Left IJ temp
dialysis cath placed [**11-3**] by IR
Pertinent Results:
Liver US [**10-30**]:
1. Marked gallbladder wall edema with an effaced, non-distended
gallbladder lumen is noted, without intrahepatic biliary ductal
dilatation. There is minimal pericholecystic fluid.
2. Dilatation of the proximal CBD.
3. Prominent periportal lymphadenopathy, nonspecific.
.
CxR [**10-31**]: New perihilar pulmonary edema and bilateral pleural
effusions.
.
ERCP [**10-31**]:
Ccannulation of the common bile duct. Cholangiogram
demonstrates a normal caliber of the common bile duct and
intrahepatic ducts. The cystic duct is also filled with
contrast, partially opacifying the gallbladder. No strictures
or filling defects are identified. Following cholangiogram,
there is placement of a plastic stent within the common bile
duct.
.
CT Chest/Abd/Pelvis [**10-31**]:
1. Multifocal pulmonary opacities, which could represent an
infectious process.
2. Bilateral axillary and right hilar lymphadenopathy, all
could be related to the underlying infectious process.
3. Moderate bilateral pleural effusions.
4. Although there is ascites, fluid within the lesser sac and
adjacent to the pancreatic head raises the suspicion of
pancreatitis.
5. Splenomegaly.
6. Periportal lymphadenopathy.
.
Echo [**11-1**]: No evidence of endocarditis. Normal global and
regional
biventricular systolic function. Mild mitral regurgitation.
.
Immunophenotyping [**11-2**]: Pending
.
Bronchial washings [**11-2**]: NEGATIVE FOR MALIGNANT CELLS.
Pulmonary macrophages. No viral cytopathic changes or
microorganisms seen.
.
R LENI [**11-6**]: No evidence of right lower extremity DVT.
.
CXR [**11-7**]: Pulmonary edema, now mild, has improved
substantially since [**11-5**]. A relatively rapid onset
between [**10-30**] and 16 and pace of improvement suggests the
diagnosis is cardiogenic rather than noncardiac edema. Heart is
normal size. There is no mediastinal or pulmonary vascular
engorgement. Lungs are clear aside from bands of atelectasis.
Other pleural surfaces are normal except for mild thickening
associated with fractures of left ribs at least the fifth, which
may have developed between [**11-2**] and 21. Tip of the right
jugular line projects over the junction of the brachiocephalic
veins and a left internal jugular line ends in the upper SVC.
.
CT abd/pelvis [**11-7**]:
1. Slightly increased amount of intraabdominal simple free
fluid.
2. Interval placement of CBD stent with collapsed, edematous
gallbladder.
3. Pancreas appears similar to previous exam.
.
CT Head [**11-7**]:
1. No acute intracranial hemorrhage or mass effect.
2. Interval opacification of multiple mastoid air cells.
.
[**2118-10-30**] 09:46PM BLOOD HCV Ab-NEGATIVE
[**2118-10-31**] 10:21PM BLOOD HIV Ab-NEGATIVE
[**2118-10-30**] 09:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HAV-NEGATIVE
[**2118-11-21**] 06:30AM BLOOD TSH-2.9
[**2118-10-31**] 10:21PM BLOOD calTIBC-156* VitB12-1420* Folate-14.4
Hapto-65 Ferritn-6065* TRF-120*
[**2118-11-5**] 02:36AM BLOOD Lipase-760*
[**2118-11-23**] 06:25AM BLOOD Lipase-242*
[**2118-10-30**] 01:20PM BLOOD ALT-81* AST-240* AlkPhos-294*
Amylase-147* TotBili-8.9* DirBili-7.4* IndBili-1.5
[**2118-11-1**] 11:35PM BLOOD ALT-90* AST-361* LD(LDH)-665*
CK(CPK)-725* AlkPhos-217* Amylase-203* TotBili-7.5*
[**2118-11-24**] 06:20AM BLOOD ALT-85* AST-21 AlkPhos-136* TotBili-1.7*
[**2118-10-30**] 01:20PM BLOOD UreaN-16 Creat-1.0 Na-131* K-4.1 Cl-98
HCO3-24 AnGap-13
[**2118-11-4**] 06:30PM BLOOD Glucose-111* UreaN-88* Creat-7.1* Na-130*
K-4.9 Cl-98 HCO3-18* AnGap-19
[**2118-11-25**] 07:40AM BLOOD Glucose-87 UreaN-30* Creat-1.1 Na-138
K-3.8 Cl-105 HCO3-25 AnGap-12
[**2118-11-2**] 03:23AM BLOOD WBC-3.5* Lymph-17* Abs [**Last Name (un) **]-595 CD3%-97
Abs CD3-580 CD4%-89 Abs CD4-532 CD8%-8.5 Abs CD8-51*
CD4/CD8-9.9*
[**2118-11-25**] 07:40AM BLOOD Gran Ct-70*
[**2118-10-30**] 01:20PM BLOOD WBC-2.0* RBC-3.50* Hgb-11.5* Hct-33.5*
MCV-96 MCH-32.8* MCHC-34.3 RDW-15.6*
[**2118-11-25**] 07:40AM BLOOD WBC-0.4* RBC-2.72* Hgb-8.1* Hct-22.6*
MCV-83 MCH-29.9 MCHC-35.9* RDW-14.7 Plt Ct-81*#
[**2118-11-17**] 02:14PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
Lymphs-87 Monos-13
[**2118-11-1**] 11:34PM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-3* Polys-0
Lymphs-95 Monos-0 Macroph-5
[**2118-11-1**] 11:34PM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-32*
Polys-0 Lymphs-67 Monos-0 Macroph-33
[**2118-11-17**] 02:13PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-61
[**2118-11-1**] 11:34PM CEREBROSPINAL FLUID (CSF) TotProt-19 Glucose-63
.
BM Bx
ERYTHROID-DOMINANT MARROW WITH INCREASED HEMOPHAGOCYTIC
HISTIOCYTES, DECREASED CELLULAR DENSITY, AND INCREASED
BACKGROUND EOSINOPHILIC CELL DEBRIS, CONSISTENT WITH
HEMOPHAGOCYTIC SYNDROME (HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS
Brief Hospital Course:
Hospital Course:
.
# Fever/Pancytopenia/ID/Hemophagocytic Lymphohistiocytosis: Pt
had been afebrile since [**11-4**] and all ABX d/c'ed on [**11-6**],
however, Vanco/Ceftaz were restarted on [**11-7**] for Tm of 102.2.
Concern was for VAP given increased respiratory secretions vs
recurrent pancreatitis with pseudocyst as pancreas enzymes were
rising after recently having restarted TF. CT Abd/pelvis was
without evidence of worsening radiographic pancreatitis. Other
sources considered included line infections (Right IJ recently
replaced in same site) or C. diff given prolonged ABX course.
.
Extensive prior infectious workup had revealed a positive EBV
IgM, EBV PCR, and EBV PCR in CSF. Given pancyotpenia,
splenomegaly, and EBV infection Heme/Onc and ID were considered
the diagnosis of Hemophagocytic Lymphohistiocytosis, which was
confirmed by repeat bone marrow biopsy (first biopsy
unremarkable). Pt was begun on etoposode, IVIG and decadron on
~[**11-7**]. His pancytopenia was also treated with epogen and
neupogen.
.
Per HEME, HLH likely triggered by underlying EBV infection.
While there was evidence of EBV in the CSF; because of normal
Protein no need for IT-MTX. The patient was started on a
steroid taper (currently on 10 mg Decadron) and will need 8
weeks total of Etoposide. Renal failure, pancreatic
abnormalities, and elevated LFTs all thought to be d/t
underlying HLH. In addition, ID consults did not recommend
treating EBV viremia with anti-virals.
.
On [**11-9**], pt was noted to have EBSL klebsiella in a sputum and
BAL sample, and was begun on meropenem for 14 day course. He
continued to develop low grade temperature (100.0-100.6), which
were attributed to his HLH, IVIG, and CVVHD.
.
# Respiratory Failure: Pt intubated on [**2118-10-30**] for impending
respiratory distress at time of his ERCP. Upon admission to the
[**Hospital Unit Name 153**] on [**11-7**], his respiratory mechanics had improved
considerably, and he was oxygenating and ventilating well on PS
5/0. Initially unable to extubate secondary to altered mental
status and increased secretions. Pt was often desyncrhonous on
vent secondary to hiccups when sedation weaned. As mental
status improved gradually, pt was extubated on [**11-10**]. His
respiratory status continued to improve slowly, despite +BAL for
EBSL klebsiella and total body fluid overload, and on [**11-14**] pt
was sat'ing >95% on RA.
.
# Mental Status - pt presented to [**Hospital1 18**] alert & oriented,
however his mental status subsequently declined. After
intubation on [**10-30**], pt remained largely sedated until just
prior to admission to the [**Hospital Unit Name 153**] on [**11-7**]. Attempts to wean
sedation were limited by hiccups which resulted in dysynchrony
the mechanical ventilation, breif neuro exam at time of [**Hospital Unit Name 153**]
admission with sedation weaned revealed pt responsive only to
deep painful stimulus (sternal rub), pupils minimally reactive
to light bilaterally, gag was present, with slow corneal reflex.
+hyperreflexia, though tone was flacid, and 5-10 beat clonus of
both feet was noted which initially worsened to 20 beat clonus
on [**11-11**] before slowly improving.
.
Was seen by the neurology/psychiatry services given his new
neurological findings and h/o myasthenia [**Last Name (un) 2902**] (which
predominantly was ocular per pt's family). EEG was obtained
which showed diffuse slowing, but no focus of seizure activity.
CT head on [**11-7**] unremarkable. Over the course of his first week
in the [**Name (NI) 153**], pt's mental status improved dramatically,
presumably with chemotherapy. By [**11-14**] pt was alert, pleasantly
conversive, and following all commands. His imuran for
myasthenia [**Last Name (un) 2902**] has been held since admission. Neuro also
noted proximal weakness of his arms, which improved during his
hospital course. Per Neruo, he should hold Imuran until he
follows up with Neuro as an outpatient.
.
# Renal - pt without h/o CRI, developed ARF likely secondary to
ATN from hypotension and underlying HLH on [**11-1**]. Pt was
started on CVVHD at that time for volume overload [**2-17**] anuria,
however, UOP gradually improved, and on [**11-15**] pt was
discontinued from HD. Creatinine normal on discharge.
.
# Cholestasis/hepatitis/pancreatitis - pt presented to [**Hospital1 18**]
from OSH with RUQ pain, fever, and elevated LFTs (Tbil 7's), for
which he underwent ERCP with CBD stent on [**11-2**]. LFTs have
since trended down, though amylase/lipase (peak in 1000s) were
starting to plateau at 500s on [**11-14**]. CT abdomen showed
pancreatic fluid collection, but not psuedocyst or necrosis. On
[**11-13**] pt denied abdominal pain, and was hungry, thus was
transitioned from TPN to TF cautiously, as prior attempt to
restart tube feeds was limited by bump in amylase/lipase. On
[**11-14**], pt was tolerating TF without difficulty, in addition to
sips of clear liquids, thus he was advanced to a regular diet
after a speech & consult was obtained. On the floor, he
tolerated his diet without other clinical s/sx of pancreatitis.
.
Psych: thought the patient had a mild encephalopathy that was
slowly resolving. Recommeded Haldol/Seroquel for sleep;
however, this made the patient feel strage. Given resolution of
MS changes, ok for patient to receive ambien at rehab prn.
.
HTN: kept on Lopressor 100 mg TID with excellent results.
Medications on Admission:
Imuran, Imitrex, Amoxicillin, Augmentin, Atovaquone, Azithromax
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every eight (8) hours: please continue until ANC
>500.
Disp:*qs mg* Refills:*2*
3. Dexamethasone 4 mg Tablet Sig: 2.5 Tablets PO once a day:
Please give 10 mg PO daily until [**12-5**]; then begin 5 mg po
daily.
Disp:*qs Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
Disp:*qs Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: while on
steroids.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs qs* Refills:*0*
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*qs qs* Refills:*2*
8. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Please continue until ANC >500.
.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Hemophagocytic lymphohistiocytosis
2. Acute Renal Failure, resolved
3. Elevated LFTs secondary to Obstruction/HLH
4. Elevated amylase/lipase, likely secondary to HLH
5. Myasthenia [**Last Name (un) **], stable
6. Hospital Acquired PNA (Klebsiella)
7. Pancytopenia/Febrile Neutropenia
8. Sepsis
9. Respiratory Failure
10. Hypertension
Discharge Condition:
stable
Discharge Instructions:
Please contact Dr.[**Name (NI) 3588**] office or your PCP should you
develop any fevers, chills, sweats, abodminal pain, nausea,
vomiting, or any other complaints.
Please make an appointment to see your outpatient Neurologist as
soon as possible.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2118-11-30**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2118-11-30**] 11:00
Someone from the Gastroenterology Team will be calling you at
Rehab regarding pulling the stent from your liver.
Please f/u with your neurologist as an outpt.
|
[
"707.8",
"733.09",
"577.0",
"584.5",
"482.0",
"518.81",
"573.3",
"428.0",
"275.41",
"277.89",
"358.00",
"995.92",
"401.9",
"785.52",
"786.8",
"038.8",
"576.1",
"284.8",
"E932.0",
"349.82",
"075"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"51.87",
"39.95",
"38.93",
"96.72",
"00.17",
"33.24",
"99.14",
"38.95",
"99.04",
"99.05",
"99.07",
"96.6",
"96.04",
"41.31",
"03.31",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
14587, 14666
|
7792, 7792
|
348, 469
|
15056, 15065
|
3076, 7769
|
15361, 15845
|
2302, 2319
|
13336, 14564
|
14687, 15035
|
13248, 13313
|
7809, 13222
|
15089, 15338
|
2334, 3057
|
278, 310
|
497, 1831
|
1853, 1994
|
2010, 2286
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,801
| 139,368
|
21794
|
Discharge summary
|
report
|
Admission Date: [**2110-7-6**] Discharge Date: [**2110-7-7**]
Date of Birth: [**2038-7-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Unresponsive.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 71 yo male with multiple vascular risk factors
including diabetes mellitus, hypertension, hyperlipidemia,
peripheral vascular disease, CAD s/p MI s/p CABG, myelodysplasia
who was found unresponsive in bed by his wife on the morning of
presentation. He was recently discharged from the vascular
surgery service on [**2110-7-3**] after having a transmetatarsal
amputation of the left foot for severe PVD. Since his discharge,
he had been doing remarkably well. He went to bed on the night
prior to admission as usual and appeared completely normal to
his wife. The next time she saw him was 9:00 AM (she does not
sleep in same room) when she attempted to wake him for breakfast
in bed. He did not wake up so she left the breakfast by the bed
and left the room. She came back about an hour later and he had
not yet woken up to eat. She thought this was unusual and more
vigorously tried to awaken him. He was unresponsive. She said
that his eyes were "wandering around" and that he was gurgling
on what apeared to be vomit. She called 911. EMS arrived to find
him unresponsive with "shallow breathing". He was intubated in
the field and he was initially brought to [**Location 17065**] ER. He
arrived there at 11:15AM. His HR was 113 BP 171/95. He was
unresponsive on arrival, but was noted to occasionally reach for
ETT with his right hand. He was given 1mg of Ativan for unclear
indications. He was also given lasix 60mg IV and Cardizem 20mg
for tachycardia. He had a head CT which showed a large stroke
with a question of hemorrhagic transformation and he was
tranfered here for further mangement.
When he arrived at the [**Hospital1 18**] ER, he remained unresponsive,
occasionally moved right arm spontaneously. ER course here was
notable for episode of junctional tachycardia which responded to
Cardizem.
Past Medical History:
DM2 x 5years
HTN
High cholesterol
CAD-s/p MI, S/p 5 Vessel CABG in [**2103**]
CHF-last echo showed EF 30% as well as inferior wall, septal and
apical hypokinesis
PVD-s/p fem-[**Last Name (un) 18709**] BRG with NRSVG [**8-25**], s/p left transmetatarsal
amputation [**6-27**]
CRI
Anemia/myelodysplasia
Glaucoma (left eye)
Social History:
20 pack year smoking history. The pt lives with wife. Denies
EtOH.
Family History:
Non-contributory
Physical Exam:
Vitals: Tm100.4 BP195-220/100-110 HR82-147 RR18 O2 Sat%
Gen: Intubated, occasional spontaneous movement of both legs
HEENT: NC/AT, ETT and NGT in place
Neck: supple, no bruit, hyperdynamic carotid pulses bilaterally.
CV: RRR, Nl S1 and S2 +S3, 3/6 SEM
Lung: Course BS anteriorly anteriorly
Abd: +BS soft, non-distended
Ext: bilateral pitting pedal edema
Neurologic examination:
Mental status: Unresponsive, does not open eyes to verbal or
tactile stimulation. Grimaces to noxious stim. Doesn't follow
commands.
Cranial Nerves:
No blink to threat. Pupils: R-4mm, reactive; L: opacified,
+corneal on right, no response on left. Roving, conjugate eye
movements bilaterally. +gag
Motor:
Normal bulk bilaterally. Tone normal. Withdraws right UE
reliably
to painful stim, occasionally withdraws right LE (inconsistent).
No withdrawal on left, triple flexion of left leg to noxious.
Sensation: Withdrawal as above
Reflexes:
brisk and symmetric throughout
spotaneous tripple flexion of left leg
Toes upgoing bilaterally
Pertinent Results:
From OSH:
BNP 4745
Trop: (?I vs T): 0.2, CK 218 MB 6.1
Here:
139 | 103 | 52 / 310 AGap=19
4.6 | 22 |1.9 \
Ca: 9.3 Mg: 1.5 P: 3.4
CK: 206 MB: 6 Trop-*T*: 0.16
TOX:
Urine- Benzos Pos, Urine Barbs, Opiates, Cocaine, Amphet, Mthdne
Negative
Serum- ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
15.0 \ 12.3 / 493
/ 35.8 \
N:89.3 Band:0 L:7.5 M:3.0 E:0 Bas:0.1
PT: 13.9 PTT: 25.2 INR: 1.3
UA: prot 100, nit neg, LE neg, RBC [**1-25**], WBC [**1-25**]
CT SCAN (from OH)-limited study, shows large area of hypodensity
with edema in the R MCA distribution, with mass effect on the
lateral ventrical and slight shift (5mm). There are several
areas of hyperintensity within the right frontal lobe suspicious
for hemorrhage. There is also a hypodense area in the left
caudate and int capsule. ? heterogenous appearing surrounding
area suspicious for evolving infarct. Hyperdense R MCA sign
CT Head ([**2110-7-6**]): Appearance of MCA stroke, shift and edema
unchanged, two areas of hyperintesity in the right frontal lobe
(2mm) that may represent petechial hemorrhage within the
infarct. These have not progressed from the last CT scan. The
left BG hypodense area is again seen-? evolving infarct.
CT HEAD ([**2110-7-7**]): There has been interval progression of the
large right- sided middle and anterior cerebral artery
infarctions, with severe edema, mass effect, and contralateral
shift of normally midline structures. There has been progression
of subfalcine herniation since the prior study. There are
several prominent foci of hyperdensity anteriorly, likely
representing hemorrhagic transformation, the largest of which is
approximately 2cm in size. The contralateral ventricle is
dilated, likely due to obstruction at the level of the foramen
of [**Last Name (un) 2044**].
IMPRESSION: Marked interval worsening of cerebral edema, mass
effect, and subfalcine herniation secondary to the large right
anterior and middle cerebral artery infarctions. Multiple areas
of interval hemorrhagic transformation.
Brief Hospital Course:
The patient was initially started on a mannitol drip. The
neurosurgery service was consulted and recommended no surgical
intervention given the grave prognosis. His condition was
unchanged from admission on the morning of the second hospital
day, roughly 24 hours after he was initially found unresponsive.
A family meeting was held with the patient's wife and children
to discuss goals of care. They had initially decided to pursue
all measures possible to sustain the patient's life despite the
poor prognosis. Later in the afternoon of the second hospital
day, the patient's nurse discovered a large and unreactive pupil
on the right on routine neuro check. The neurology and
neurosurgery teams were called to evaluate the patient and this
finding was confirmed. A repeat CT scan of the head was
performed which demonstrated an increase in the size of the
infarction in the right hemisphere with increased edema,
worsened subfalcine and uncal herniation. Another family
meeting was held to readdress goals of care given the turn of
events. It was eventually decided by the patient's wife and
children to shift the goals of care to focus on the patient's
comfort. He was extubated and all medications with the
exception of a morphine gtt were discontinued. The patient
passed away at 11pm on [**2110-7-7**]. A post-mortem
examination was declined by the patient's wife.
Medications on Admission:
Simvastatin 10 mg DAILY
Paroxetine HCl 40 mg PO DAILY
Furosemide 80 mg PO BID
Docusate Sodium 100 mg PO BID
Glipizide 5 mg PO BID
Carvedilol 6.25 mg PO BID
Lisinopril 10 mg PO DAILY
Metronidazole 500 mg PO TID
Atorvastatin Calcium 10 mg PO DAILY
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Right anterior cerebral, middle cerebral, posterior cerebral
infarction with associated edema and brain herniation.
Discharge Condition:
Deceased.
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"272.0",
"V45.81",
"401.9",
"428.0",
"434.91",
"599.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"38.91",
"96.71",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
7461, 7470
|
5750, 7135
|
328, 335
|
7639, 7650
|
3705, 5727
|
7702, 7708
|
2638, 2656
|
7433, 7438
|
7491, 7618
|
7161, 7410
|
7674, 7679
|
2671, 3026
|
275, 290
|
363, 2190
|
3199, 3686
|
3065, 3183
|
3050, 3050
|
2212, 2536
|
2552, 2622
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,750
| 120,236
|
54509+59616
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-6-24**] Discharge Date: [**2193-7-15**]
Date of Birth: [**2119-3-10**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 74 year old, white
female patient, who underwent coronary artery bypass graft
times four in [**2176**], now presenting with increasing dyspnea on
exertion. She had a follow-up cardiac catheterization in
[**Month (only) 547**] of this year for increasing symptoms as well as known
aortic stenosis. This revealed patent left internal mammary
artery to the left anterior descending graft, as well as
patent saphenous vein to the right coronary with saphenous
vein graft to the obtuse marginal one, jump graft to the
obtuse marginal two occluded. This also revealed aortic
stenosis with an aortic valve area of 0.8 cm square and a
peak gradient of 50 mm. A left ventricular ejection fraction
was 62 percent at that time and she also had 1 plus mitral
regurgitation. She was referred for a redo coronary artery
bypass graft as well as aortic valve replacement.
PAST MEDICAL HISTORY: Significant for prior cardiac surgery,
as previously stated. Prior angioplasty in [**2175**].
Hypertension. Hypercholesterolemia. Non insulin dependent
diabetes mellitus. Osteoarthritis of her back. Depression.
Gastroesophageal reflux disease. Anemia. Hypothyroidism.
Aortic stenosis. Mitral regurgitation. Status post total
abdominal hysterectomy. Status post bladder suspension.
Status post Cesarean section. Status post left shoulder
surgery. Status post back surgery.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q. Day.
2. Atenolol 100 mg p.o. q. Day.
3. Cardizem CD 240 mg p.o. q. Day.
4. Imdur 120 mg p.o. q. Day.
5. Zoloft 150 mg p.o. twice a day.
6. Prilosec 20 mg p.o. q. Day.
7. Avandia 4 mg p.o. q. Day.
8. Lipitor 20 mg p.o. q. Day.
9. Slow Niacin 250 mg p.o. q. Day.
10. Isosorbide 60 mg p.o. twice a day.
11. Bextra 20 mg p.o. q. Day.
12. Synthroid 175 mcg p.o. q. Day.
13. Iron supplement.
ALLERGIES: The patient states an allergy to Kefzol.
SOCIAL HISTORY: The patient is a former heavy smoker, quit
17 years ago and denies alcohol use.
HOSPITAL COURSE: The patient was admitted to the hospital on
the day prior to planned surgery for intravenous diuresis
with Lasix. However, on preoperative evaluation, she was
found to be thrombocytopenic with a platelet count in the
90's. For that reason, her surgery was initially cancelled
and hematology consult was obtained. After a few days on the
medical floor and follow-up with the hematology service, it
was felt that she had ITP and that it was safe to proceed
with surgery. The patient was subsequently taken to the
operating room on [**2193-6-28**] where she underwent coronary
artery bypass graft redo, times one to the right coronary
artery as well as an aortic valve replacement with a 23 mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. Postoperatively, she
was on Milrinone, epinephrine, Neo-Synephrine, insulin,
intravenous drips and Propofol and was transported from the
operating room to the cardiac surgery recovery unit in good
condition.
On postoperative day number one, the patient extubated
herself. It would not have been the plan to extubate her, as
she did not have a cuff leak and there were concerns about
airway edema. She was, at that time, treated with
intravenous steroids and she remained extubated. She also
discontinued her central line about the same time. She
continued to remain restless and quite agitated over the next
few days and ultimately required reintubation early in the
morning of [**7-1**], due to increasing respiratory distress,
tachypnea and hypoxia. She also had a new left femoral
central line placed at that time for intravenous access.
Pulmonary medicine consultation was obtained at that time.
She was started on intravenous Presidex to help with her
agitation issues. She was treated aggressively with steroids,
maintained on ventilatory support over the next few days.
She was ultimately extubated successfully on [**7-3**],
postoperative day number five, and has remained extubated
with stable respiratory status. It did, however, take a
number of days for her mental status to clear. During her
mental status work-up, she was found to have urinary tract
infection. This was found to be resistant pseudomonas for
which she was placed on intravenous Zosyn. She has
subsequently had a repeat urine culture from [**7-10**] which
was negative and she received a full seven day course of
intravenous Zosyn. Over the next few days, her mental status
continued to clear but, because she was not completely lucid
on [**7-5**], a neurology consult was obtained. CT scan of
her head was obtained and there was no acute infarction shown
and no intracranial hemorrhage. It was the recommendation of
the neurology service to continue with the patient,
aggressively treat the urinary tract infection and avoid all
sedating medications. The patient was ultimately transferred
for the cardiac surgery Recovery Room to the postoperative
telemetry floor on [**7-8**]. Because of continued
agitation, a psychiatry consult was obtained. The patient's
agitation had been treated with intravenous Haldol and it was
the recommendation of the psychiatry consult service to
continue with intravenous Haldol with maintenance, as well as
with prn dosing. It was also advised that patient have a one-
to-one sitter, as long as she was agitated for patient safety
reasons.
Over the next few days, the patient was noted to have some
sternal drainage at the distal portion of her sternal wound.
There was no surrounding erythema and the wound ultimately
dehisced a small area, about 4 cm in length and maybe 1 cm
deep. It remained clean, without erythema or purulent
drainage, with just some serosanguinous drainage
intermittently. Wet to dry dressings had been applied to
that wound. The patient had a PICC line placed on [**7-10**]
to facilitate continued need for Zosyn. Over the next few
days, her mental status improved significantly and the sitter
was discontinued by [**7-12**]. She remained hemodynamically
stable throughout, in normal sterile fashion, with room air
oxygen saturation in the mid to high 90's. Her Haldol was
ultimately weaned over the next few days and discontinued
today, on [**7-15**]. The patient's condition today is as
follows: Neurologically, she is alert and oriented with no
complaints. Her temperature is 97.8. Heart rate 67 and normal
sinus rhythm. Respiratory rate 18. Blood pressure 131/52.
Room air oxygenation is 98 percent. She is alert and
oriented with no apparent deficits today. Pulmonary
examination: Lungs are clear to auscultation bilaterally.
Coronary examination: Regular rate and rhythm. Abdomen is
soft and obese, nontender. Extremities: Warm and well
perfused with no evidence of peripheral edema. As previously
stated, the lower pole of the posterior wound remains open,
approximately 4 cm in length, with no erythema and no
purulent drainage. She also has a very small, left groin
wound that is open, approximately a cm to 2 cm in length and
she also has some yeast in the groin area.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg p.o. twice a day.
2. Colace 100 mg p.o. twice a day.
3. Enteric coated aspirin, 325 mg p.o. q. Day.
4. Captopril 12.5 mg p.o. three times a day.
5. Zoloft 200 mg p.o. q. Day.
6. Vioxx 25 mg p.o. q. Day.
7. Protonix 40 mg p.o. q. Day.
8. Avandia 4 mg p.o. q. Day.
9. Lipitor 20 mg p.o. q. Day.
10. Synthroid 150 mg p.o. q. Day.
11. Zosyn 2.25 grams intravenous q. Six hours throughout
completion of dosing on [**7-16**], which will be her
seventh day.
12. Haldol is discontinued today.
13. Heparin 5000 units subcutaneous twice a day until
the patient is fully ambulatory.
14. Lasix will be discontinued prior to discharge.
DISCHARGE DIAGNOSES: Aortic stenosis, status post aortic
valve replacement.
Coronary artery disease status post coronary artery bypass
graft.
Postoperative delirium.
Postoperative urinary tract infection.
DISCHARGE INSTRUCTIONS: The patient is to be discharged
today. She is to follow-up with her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 9960**], at [**Hospital6 3872**] in one to two weeks.
She is to follow-up with her cardiologist, Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) **], [**Hospital6 3872**], in one to two weeks. She
is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in two to three
weeks for postoperative check.
DISCHARGE CONDITION: Good.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2193-7-15**] 12:11:26
T: [**2193-7-15**] 13:08:52
Job#: [**Job Number **]
Name: [**Known lastname 18340**], [**Known firstname 565**] Unit No: [**Numeric Identifier 18341**]
Admission Date: [**2193-6-24**] Discharge Date: [**2193-7-18**]
Date of Birth: [**2119-3-10**] Sex: F
Service: CSU
The patient had remained in the hospital due to inability to
obtain a rehabilitation bed for her. She now, however, has a
bed and will be transferred to rehabilitation today to
progress her cardiac rehabilitation and increase her
mobility. In the interim while she has remained in the
hospital, she has completed her course of Zosyn for the
previously described resistant urinary tract infection and
therefore, her PICC line has been removed. There are no other
changes in her discharge medications or in her condition. She
has remained hemodynamically stable throughout with no change
in her physical examination.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 3125**]
Dictated By:[**Last Name (NamePattern1) 10301**]
MEDQUIST36
D: [**2193-7-18**] 13:26:59
T: [**2193-7-18**] 13:52:45
Job#: [**Job Number 18342**]
|
[
"998.32",
"424.1",
"293.0",
"998.83",
"287.3",
"424.0",
"414.02",
"518.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"35.22",
"36.15",
"99.15",
"38.93",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8651, 10031
|
7912, 8100
|
7212, 7890
|
1570, 2058
|
2174, 7189
|
8125, 8629
|
165, 1037
|
1060, 1544
|
2075, 2156
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,600
| 109,366
|
50654
|
Discharge summary
|
report
|
Admission Date: [**2168-8-28**] Discharge Date: [**2168-8-31**]
Date of Birth: [**2093-9-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
woman with chronic obstructive pulmonary disease,
interstitial lung disease (on home oxygen), end-stage renal
disease (on hemodialysis), and critical aortic stenosis who
came to the Emergency Department on [**8-28**] complaining
of increased shortness of breath for the past two weeks.
She was recently admitted to [**Hospital1 188**] and discharged home on [**8-14**] with similar
complaints. At that time, she was diagnosed with fluid
overload and a questionable pneumonia. She was treated with
three days of levofloxacin which was discontinued prematurely
secondary to the side effects of diarrhea.
Since her discharge, the patient continued with hemodialysis
three times per week at [**Hospital1 1474**] where she had been complaint
with hemodialysis sessions. Her last hemodialysis was two
days prior to arrival when she had a hypertensive episode
during the [**Hospital1 2286**] (her blood pressure at that time was
unknown and the amount of fluid taken off was also unknown).
The daughter reports that the patient has had a history of
hypertension during hemodialysis in the past; more than six
months ago. She has a history of poor compliance with fluid
restriction. In addition to her shortness of breath, she
also complained of lightheadedness when changing position.
On the morning of admission, she sat up on the edge of her
bed and fell onto a soft carpet hitting her face. She denied
loss of consciousness.
REVIEW OF SYSTEMS: Review of systems was positive for
dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,
an occasional productive cough of yellow sputum, and
lightheadedness. Review of systems was negative for chest
pain, diaphoresis, neck or arm pain, or dysuria (she has
oliguria). Review of systems was also negative for fevers,
chills, nausea, vomiting, visual changes, or weight loss.
In the Emergency Department, on [**8-28**], the patient was
seen by the Renal Service in consultation who felt she should
be transferred to the Medical Intensive Care Unit for two
liters of ultrafiltration. It was thought she needed
Intensive Care Unit observation secondary to her history of
hypertension during hemodialysis.
In the Emergency Department, the team tried to get a head
computed tomography but the patient was unable to lay flat
secondary to her fluid overload. However, the patient did
not show any neurologic changes at that time.
PAST MEDICAL HISTORY:
1. End-stage renal disease (on hemodialysis on Monday,
Wednesday, and Friday).
2. Chronic obstructive pulmonary disease.
3. Interstitial lung disease (on home oxygen with 2 liters
nasal cannula).
4. Compression fracture.
5. Aortic stenosis with an aortic valve area of 0.6 cm2 and
a peak velocity of 70 mmHg.
6. Paroxysmal atrial fibrillation.
7. History of pericardial effusion.
8. Depression.
9. Status post abdominal aortic aneurysm in [**2159**].
10. Pulmonary artery hypertension; moderate.
11. Echocardiogram on [**8-11**] revealed an ejection
fraction of 60%, 1+ aortic regurgitation, 2+ mitral
regurgitation, and 2+ tricuspid regurgitation.
MEDICATIONS ON ADMISSION:
1. Renagel 800 mg by mouth three times per day
2. Prozac 20 mg by mouth once per day.
3. Fosamax 70 mg by mouth every Monday.
4. Serax 15 mg by mouth q.h.s.
5. Calcium carbonate 1500 mg by mouth once per day.
6. Atenolol 25 mg by mouth once per day.
7. Albuterol as needed.
8. Calcitonin.
9. Atrovent.
10. Dilaudid 2 mg to 4 mg by mouth q.4-6h. as needed.
11. Prednisone taper from her last admission which was
discontinued on [**8-23**].
ALLERGIES: CODEINE (leads to pruritus) and PERCOCET (leads
to nausea).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed her temperature was 97.8 degrees
Fahrenheit, her heart rate was 89, her blood pressure was
147/67, respiratory rate was 20, and her oxygen saturation
was 97% on 4 liters nasal cannula. Generally, the patient
was an elderly woman in mild respiratory distress with the
head of the bed at 30 degrees, using accessory muscles.
Head, eyes, ears, nose, and throat examination revealed
normocephalic and atraumatic. Pupils were equal, round, and
reactive to light. The oropharynx was clear. The mucous
membranes were dry. On neck examination, the patient had
jugular venous distention up to her ears. Lung examination
revealed she had rales bilaterally up to the her apices with
intermittent wheezes at the left upper lobe. Cardiovascular
examination revealed the patient had a [**2-25**] harsh systolic
ejection murmur throughout her precordium which was heard
best at the right upper sternal border with radiation to the
neck. A regular rate and rhythm. The abdomen was soft,
nontender, and nondistended. Normal active bowel sounds.
Extremity examination revealed she had 3+ lower extremity
edema up to the thighs. Some pedal petechiae. An
arteriovenous fistula in her left arm used for hemodialysis.
Neurologic examination revealed the patient was alert and
oriented times three. She moved all extremities. Cranial
nerves II through XII were intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed her white blood cell count was 7.3, her
hematocrit was 36.1, and her platelets were 152. Her sodium
was 132, potassium was 5, chloride was 89, bicarbonate was
32, blood urea nitrogen was 31, creatinine was 4.3, and her
blood glucose was 116. Initial creatine kinase was 14.
Troponin was 0.15.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative for
consolidations or effusions. There was mild edema and
chronic idiopathic fibrotic changes.
Electrocardiogram revealed a normal sinus rhythm, right axis
deviation, normal intervals, with an old right bundle-branch
block pattern. There were old T wave inversions in V1
through V3, and leads III and aVF.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RENAL ISSUES: The patient was admitted to the Medical
Intensive Care Unit for monitoring during ultrafiltration.
On [**8-28**], she had 2.3 liters taken off and she
symptomatically improved in terms of her shortness of breath.
Her lower extremity edema also resolved as well. The
following day she had her regular hemodialysis; at which time
they took off 3 liters, and she continued to feel even better
than her baseline in terms of her breathing.
Her sodium did drop during her admission from 132 to 128.
She was kept on a 1-liter fluid restriction, and the plan was
to undergo one final hemodialysis prior to discharge this
afternoon; and hopefully her hyponatremia will correct.
2. PULMONARY ISSUES: The patient has a long history of
interstitial lung disease and chronic obstructive pulmonary
disease. She was on 2 liters of oxygen at home, and she
remained on this regimen while in house, and her oxygen
saturations remained between 94% and 100%. She felt
symptomatically improved following each hemodialysis session
and reported her breathing was better than her baseline.
3. CARDIOVASCULAR ISSUES: The patient has a long history of
aortic stenosis and was seen by the Cardiology approximately
one year ago; at which time no intervention was felt to be
needed.
However, on a more recent echocardiogram this past [**Month (only) 216**] it
was found that she had severe aortic stenosis with an aortic
valve area of 0.6 cm2.
The Cardiology Service was consulted during this admission to
discuss possible treatment of her aortic stenosis, and it was
felt that due to her comorbidities any operative risks (in
terms of an aortic valve replacement) would be extremely high
and was not an option at this time. They also discussed the
option of a valvuloplasty, which they felt would not be
beneficial in this case.
During this admission, she remained in a normal sinus rhythm.
After her initial hemodialysis, she showed no signs of heart
failure. She did have a recent echocardiogram in [**Month (only) 216**]
which showed an ejection fraction of 60%.
She initially came in on atenolol 25 mg by mouth once per day
which was held secondary to her undergoing hemodialysis
immediately upon admission. Her blood pressure remained
under control throughout this admission, and atenolol was
never given.
On admission, the patient had an elevated troponin of 0.15.
Her cardiac enzymes were cycled. Her creatine kinase levels
remained flat for five cycles. Her troponin increased from
0.15 to a peak of 0.19. It came down again to 0.17. It was
felt that this was likely secondary to the patient renal
failure and did not represent an acute myocardial infarction.
4. STATUS POST FALL ISSUES: The patient had reportedly fell
and hit her head on the carpet on the day of admission. She
had no mental status changes and no overt neurologic changes. A
complete musculoskeletal exam was performed and did not reveal
any abnormalities or injury.
A computed tomography was attempted in the Emergency
Department; however, the patient could not lay down secondary
to her orthopnea. It was decided that unless she were to
develop neurologic changes no imaging would be necessary.
She continued to be neurologically intact and without changes
throughout her hospitalization.
5. CODE STATUS: Code status was discussed with the patient
on admission, and she decided to be do not resuscitate/do not
intubate.
6. DISPOSITION ISSUES: Placement was discussed with the
patient and her daughter, and it was decided that the patient
was unable to care for herself at home and would likely need
at least [**Hospital 3058**] rehabilitation if not [**Hospital 4820**]
rehabilitation.
DISCHARGE DIAGNOSES:
1. End-stage renal disease (on hemodialysis).
2. Severe aortic stenosis.
3. Chronic obstructive pulmonary disease/interstitial lung
disease (on home oxygen).
4. Acute exacerbation of congestive heart failure.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg by mouth twice per day.
2. Fosamax 70 mg by mouth every Monday.
3. Oxazepam 15 mg by mouth q.h.s.
4. Atrovent meter-dosed inhaler 2 puffs inhaled four times
per day.
5. Albuterol meter-dosed inhaler 2 puffs inhaled q.6h.
6. Calcium carbonate 1500 mg by mouth once per day.
7. Fluoxetine 20 mg by mouth once per day.
8. Sevelamer 800 mg by mouth three times per day.
9. Albuterol nebulizers q.6h. as needed.
10. Protonix 40 mg by mouth once per day.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 105396**]
MEDQUIST36
D: [**2168-8-31**] 12:20
T: [**2168-8-31**] 13:03
JOB#: [**Job Number 105397**]
|
[
"515",
"276.1",
"585",
"496",
"428.0",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9778, 10002
|
10080, 10875
|
3293, 6031
|
6065, 9757
|
10017, 10053
|
1637, 2574
|
156, 1617
|
2597, 3266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,331
| 121,689
|
51066
|
Discharge summary
|
report
|
Admission Date: [**2170-6-12**] Discharge Date: [**2170-6-20**]
Service: EMERGENCY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
PICC placement bedside failed [**6-18**]
IR guided PICC [**6-18**]
History of Present Illness:
89 year old Russian-speaking woman with history of diastolic CHF
(EF 55%, [**4-/2170**]), COPD who lives at [**Hospital 100**] Rehab presents with
worsening hypoxia. This morning at [**Hospital 100**] Rehab, pt found to be
hypoxic to 60s at 4 am and was placed on 10L/min with
improvement to 80%. She was then weaned to 4L/min. At that
time, they noted tightness in her chest, pronounced wheezes, and
afraid to lay down.
.
She said that over the last week she has been having increased
shortness of breath and DOE. She Per reports, worsening
orthopnea over the past week as well as PND 3-4 times. She also
reports worsening cough, sputum production and new O2
requirement. She denied recent fever, chills, URI symptoms,
n/v/d, Chest pain, diaphoresis, abdominal pain, joint or muscle
pains. Recent URI. No fevers or CP by report.
.
In ED, triggered for tachypnea in 40's, with triage VS of 99.8
84 121/49 32 99% NRB. Labs notable for BNP 1759, CXR ?
infiltrate left sided, perihilar prominence. Pt received
vancomyin, zosyn, levaquin, albuterol/ipratropium neb. On exam,
coarse cough, rectal T 99, one "soft SBP of 96" and received
250cc IVF. DNR DNI
Past Medical History:
-Hypertension,
-hyperlipidemia
-Pacer for symptomatic bradycardia and afib
-Atrial fibrillation
-Alzheimer's Dementia
-Breast ca s/p mastectomy
-mild COPD
-Stroke
-osteoarthritis in knee s/p steroid injections
-low back pain [**3-7**] L2 fracture
-Rheumatoid arthritis
-Depression
Social History:
Lives at [**Hospital 100**] Rehab. russian Speaking only. Has a son who is
involved in her care. Has no history of smoking, drinking or
other drugs.
Family History:
No family history of heart disease, Diabetes,
Hypercholesterolemia, or cancer
Physical Exam:
On Admission:
VS: T: 96.0, BP: 100/53, HR: 74, RR: 22, 93% 4L, Weight 156lbs.
GA: AOx3, NAD
HEENT: EIOMI, MMM. no LAD. JVP 12cm. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: Poor air movement with diffuse crackles and wheezes
Abd: soft, NT, +BS. umbilical hernia that is easily
reproducible.
Extremities: wwp, enlarged lower extremities with extensive
varicosities
Skin:
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
.
DIscharge:
VS: T: 98.6, BP: 109/81, HR: 82, RR: 22, 96%on 2L
GA: AOx0, agitated at times
HEENT: EIOMI, MMM. no LAD. JVP 12cm. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: Poor air movement with decreased BS at bases
Abd: soft, NT, +BS. umbilical hernia that is easily
reproducible.
Extremities: wwp, 1+ edema throughout extremities
Pertinent Results:
[**2170-6-12**] 07:30PM CK(CPK)-15*
[**2170-6-12**] 07:30PM CK-MB-3 cTropnT-<0.01
[**2170-6-12**] 09:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2170-6-12**] 09:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-6-12**] 08:33AM LACTATE-0.9
[**2170-6-12**] 08:20AM GLUCOSE-132* UREA N-19 CREAT-0.7 SODIUM-142
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-31 ANION GAP-14
[**2170-6-12**] 08:20AM estGFR-Using this
[**2170-6-12**] 08:20AM ALT(SGPT)-19 AST(SGOT)-25 LD(LDH)-183 ALK
PHOS-81 TOT BILI-0.4
[**2170-6-12**] 08:20AM cTropnT-<0.01
[**2170-6-12**] 08:20AM proBNP-1759*
[**2170-6-12**] 08:20AM ALBUMIN-4.5 IRON-25*
[**2170-6-12**] 08:20AM calTIBC-497* FERRITIN-46 TRF-382*
[**2170-6-12**] 08:20AM WBC-3.5*# RBC-3.95* HGB-11.4* HCT-37.2 MCV-94
MCH-29.0 MCHC-30.8* RDW-15.4
[**2170-6-12**] 08:20AM NEUTS-84.0* LYMPHS-11.4* MONOS-3.3 EOS-1.0
BASOS-0.2
[**2170-6-12**] 08:20AM PLT COUNT-136*
[**2170-6-12**] 08:20AM PT-12.6 PTT-26.9 INR(PT)-1.1
[**2170-6-12**] 08:20AM RET AUT-1.5
.
Discharge labs:
152 | 102
--------
3.4
.
[**2170-6-20**]
[**Age over 90 **] |103| 40
------------
5.9 |40 |0.9
Ca: 10.9 Mg: 2.8 P: 2.9 ∆
Source: Line-PICC
\95/
6.0----11.1
/37.7\
.
[**6-15**] IMPRESSION:
1. No evidence of pulmonary embolism. Evaluation of the
subsegmental
arteries is limited by motion and low lung volumes.
2. Findings suggesting congestive failure, including
cardiomegaly, bilateral effusions, interstitial thickening and
edema, and contrast reflux into the hepatic veins. Marked
prominence of the main and right and left pulmonary arteries,
suggesting associated pulmonary hypertension.
3. Consolidation at the left greater than right lung bases with
associated
volume loss most likely representing atelectasis. Impaction of
the left lower lobe bronchi suggests aspiration or mucus
plugging. No definite evidence of pneumonia.
4. Small lung nodule in the left upper lobe (4 mm). Since the
patient has a risk of obstructive lung disease, follow-up CT
surveillance is recommended in one year.
.
[**6-17**] Rotated positioning. There is moderate to moderately severe
cardiomegaly. Dual-lead pacemaker is present, with lead tips
normal in position. Diffuse vascular blurring and a presumed
prominence is compatible with interstitial edema. There are
small bilateral
effusions with underlying collapse and/or consolidation.
Increased
retrocardiac density. Rounded lucency seen in the region of the
left hilum
may represent airways seen on end. No pneumothorax is detected.
.
Micro:
-All cultures negative
[**2170-6-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2170-6-14**] URINE URINE CULTURE-FINAL INPATIENT
[**2170-6-12**] URINE URINE CULTURE-FINAL INPATIENT
[**2170-6-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2170-6-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
A/P: 89 year old Russian-speaking woman with history of
diastolic CHF (EF 55%, [**4-/2170**]), COPD who lives at [**Hospital 100**] Rehab
presents with worsening hypoxia.
.
# Dyspnea: Patient with clinical history of both COPD
exacerbation as well as CHF. She presented to the floor and was
started on Prednisone 60mg ([**6-12**]), nebulizers and levofloxacin.
She was also actively diuresed. Her O2 requirement did not
improve and on day 3 she became slightly unresponsive and there
was some concern that she was going into hypercarbic respiratory
failure. pCO2 at the time was 88, but her pH was within normal
limits. She was given a face mask as opposed to nasal cannula
and her pCO2 decreased to 60s and she became slightly more
responsive. However, on day 5 of admission after sleeping for
the night she awoke and was very unresponsive and shaking. She
urinated and her shaking resolved slightly, but unresponsiveness
continued. Her pCO2 was in the 70s and continued to rise. She
was tried on BiPAP on the floor and this did not help. She was
transferred to the unit for further management on BiPAP.
Unfortunately the patient did not tolerate bipap well and it was
hard to find a mask that sealed well to her face. This was
decided not to be an option for her. Her c02 continued to climb
into the low 100s. Patient was continued on 02 to maintain sats
in the low 90s (with COPD). If her oxygen got too high, her
mental status worsened. She was treated for HAP with 10 day
course planned for Vanc/Zosyn started on [**6-16**]. She already
completed 5 day course of levaquin. She was also planned for
long steroid taper or steroids, methylpred chosen because NPO.
The methylpred 40mg IV q8h([**6-13**]) was started day prior unit
transfer. She remained on that until [**6-18**] in which she was
started on 20mg IB q8. She was tapered to 10mg IV BID today
which should be continued for [**2-4**] more days and then tapered per
[**Hospital **] rehab. She tends to be a mouth breather so sometimes
requires face mask. Only on 2L upon discharge satting 95%. Her
lasix is currently on hold and she does have dCHF. She is being
given d5w for hypernatremia and may need low dose lasix started
soon to maintain euvolemia. She should continue nebulizer
treatment.
.
# Delirium: The patient became delirious overnight on day 2 of
admission. She was mildly redirectable, but she became
increasingly agitated as the days went on and was unresponsive
to medications. This was known to occur in the past and we
thought we would be able to manage it with redirection and
medication. Her symptoms persisted and then on day 5 of
admission, she became increasingly unresponsive and was
transferred to the unit for further care. Her mental status was
felt likely due to hypercarbia and delerium made worse likely
from steroids. She was treated with zyprexa, occasional doses
of haldol and respiratory support as above. When delirious she
c/o leg pain so low dose morphine was used with zyprex. Zyprexa
5mg makes patient quite somnolent so it was titrated to 2.5mg.
Patient was not oriented throughout ICU stay although she knew
she was in the hospital.
.
# Diastolic CHF: Last ECHO in 3/[**2170**]. Has EF 55% with symmetric
LVH. Felt to be initially fluid overloaded on exam. She was
discharged from the hospital in [**Month (only) 958**] on lasix augmented by
mitolazone and unclear why it has since been discontinued. She
was aggressively diuresed on the floor and was 10Kg lighter than
her admission weight at the time of transfer to the unit. Lasix
was initially continued in the unit, but she became
hypernatremic, hypercalcemic, increasing creatinine and
increased HCT [**3-7**] hemoconcentration so lasix was stopped and she
was gently bolused with d5W. Volume status should be reassessed
in rehab.
.
#Hypernatremia: Likely from dehydration. She was repleted with
IV D5W. Na should be trended and free water replaced in rehab.
.
Leukopenia/anemia: Unlcear etiology. Has been stable to
slightly trending up since admission in [**2170-4-3**].
Differential includes myelosuppression vs. MDS vs. drug induced.
This was considered then and was trended. Hemo/onc was
consulted and beleived it was due to infection. It resolved
prior to discharge.
.
COPD: Has not been on medications in the past. However patient
wheezing on exam in the ICU so she was started on IV solumedrol
(not taking PO) and standing nebs. See discussion above.
.
Hypertension: BP well controlled bc normotensive. Metoprolol
12.5mg PO BID changed to IV while NPO. Lisinopril 5mg PO Daily
hold bc NPO.
.
hyperlipidemia: Stable. simvastatin on hold while NPO
.
Pacer for symptomatic bradycardia and afib: Will continue to
follow VS and continue BB. Metoprolol 2.5mg IV q6 started bc
patient NPO.
.
Alzheimer's Dementia/Delirium: Patient has history of
alzheimer's dementia and lives at [**Hospital **] rehab. Not on any
medications for her alzheimer's.
.
Breast ca s/p mastectomy: Has not had recurrence. Stable
.
h/o Stroke: H/o afib, asa on hold bc NPO
.
Rheumatoid arthritis/OA: S/p steroid injections to knee.
Reported leg pain when delirious, morphine, tylenol and capsacin
PRN for pain
.
Depression: Currently asymptomatic and not taking any SSRI or
other antidepressants. Will monitor for symptoms.
.
#Code: DNR/DNI
.
TRANSITIONAL ISSUES: Nutriton: patient would not participate in
S+S on Monday [**6-18**], need to be repeated at [**Hospital **] Rehab. Currently
NPO.
Medications on Admission:
Guaifenesin [**6-12**] mL PO/NG Q6H:PRN
Acetaminophen 650 mg PO/NG TID
Albuterol 0.083% Neb Soln 1 NEB IH Q4H
Ipratropium Bromide Neb 1 NEB IH Q6H
Aspirin 81 mg PO/NG DAILY
Lisinopril 5 mg PO/NG DAILY
Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]
Capsaicin 0.025% 1 Appl TP TID:PRN
Metoprolol Tartrate 12.5 mg PO/NG DAILY
Clonazepam 1 mg PO/NG QHS
Potassium Chloride 20 mEq PO DAILY
Docusate Sodium 100 mg PO BID
Furosemide 60 mg PO/NG [**Hospital1 **]
Senna 1 TAB PO/NG [**Hospital1 **]
Simvastatin 10 mg PO/NG HS
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000 U
Injection TID (3 times a day).
2. tylenol Sig: One (1) 325-560mg Rectal three times a day as
needed for pain.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebs Inhalation Q4H (every 4 hours).
4. ipratropium bromide 0.02 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours).
5. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic [**Hospital1 **]
(2 times a day).
6. capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for pain.
7. metoprolol tartrate 5 mg/5 mL Solution Sig: 2.5mg dose
Intravenous Q6H (every 6 hours): hold for sbp<90 or HR<60.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
12 hours on and 12 hours off to left knee.
9. olanzapine 2.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for agitation.
10. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. morphine 2 mg/mL Syringe Sig: One (1) mg Injection Q6H
(every 6 hours) as needed for pain.
13. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q 24H (Every 24 Hours): Started on [**6-16**].
14. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours): Started on [**6-16**].
15. methylprednisolone sodium succ 40 mg Recon Soln Sig: One (1)
Recon Soln Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Hospital Associated Pneumnia
diastolic heart failure
COPD exacerbation
Delirium
.
Secondary:
Dementia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with shortness of breath. You
were treated for pneumonia, an exacerbation of your underlying
lung disease and a little bit of heart failure. You required
transfer to the intensive care unit because you were confused at
times and required close monitor of your breathing.
.
Meds changes:
1)Aspirin 81mg, Guaifenesin PO 5-10mL P q6prn, Lisinopril 5mg PO
daily, senna/colace, lasix 60mg PO BID, and simvastatin 10mg qhs
all on hold because patient NPO
2)Metoprolol tartrate 12.5mg PO BID switched to metoprolol 2.5mg
IV q6
3)Clonazepam 1mg qhs discontinued for delirium
4)Potassium 20mg on hold as we had been repleting with her labs
5)Vancomycin 1g IV q12 to complete 10 day course (complete [**6-26**])
6)Zosyn 2.24g IV q6 to complete 10 day course (complete [**6-26**])
7)Morphine 1mg IV q6 prn pain
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with patient PCP after discharge from MACU.
Completed by:[**2170-6-21**]
|
[
"288.50",
"V12.54",
"564.00",
"518.84",
"294.10",
"486",
"272.4",
"401.9",
"715.96",
"285.9",
"E932.0",
"428.0",
"331.0",
"427.31",
"428.33",
"714.0",
"427.89",
"284.1",
"275.42",
"491.21",
"276.3",
"293.0",
"V10.3",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
13807, 13873
|
6087, 11399
|
260, 329
|
14028, 14075
|
3091, 4196
|
15153, 15245
|
2003, 2082
|
12124, 13784
|
13894, 14007
|
11578, 12101
|
14203, 15130
|
4212, 6064
|
2097, 2097
|
11420, 11552
|
213, 222
|
357, 1514
|
2111, 3072
|
14090, 14179
|
1536, 1818
|
1834, 1987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,144
| 129,025
|
51595
|
Discharge summary
|
report
|
Admission Date: [**2193-6-27**] Discharge Date: [**2193-7-1**]
Date of Birth: [**2109-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 83M with CAD s/p CABG, CHF (EF 30-40%) who
presented to his PCP's office today for pre-op evaluation for
eye surgery. The patient complained of having increased SOB over
the past week with symptoms of orthopnea, and insomnia, and
increased lower extremity edema. The patient reports taking his
lasix regularly, and not missing any doses. He also denies any
major changes to his diet or excessive salt load. Lower
extremity edema has been chronic and on-going. Baseline weight
is 190 and his weight has been up somewhat over the past week.
On arrival at the office, was found to be hypoxic to 85% on RA,
with bibasilar crackles and lower extremity edema. Other vitals
were HR- 60's BP - 126/52 RR- 20. An EKG showed afib @ a rate of
44, and he was sent to the ER for further workup.
.
In the ED, initial vitals were 96.8 65 153/62 22 100% on NRB. He
was given asa 325mg, nitroglycerin, and lasix 60mg IV with 300cc
urine output. EKG showed slow atrial fibrilation with a HR of
40-50's. Initially the patient's oxygenation status improved
with diuresis and oxygenation improved to the low 90's on 4-5L
NC. A CXR showed a substantially increased L sided pleural
effusion compared to a CXR from a month prior, and a stable R
sided pleural effusion. Awhile later, the patient was again
noted to become hypoxic on 4-5L NC with O2 sats falling to the
high 80's from the mid 90's, though on physical exam crackles
were less apparent. Patient was sent for CTA to evaluate for
possible PE. The CTA showed no evidence of PE, but did confirm
large bilateral pleural effusions, which appeared loculated on
the R, and with RLL/LLL atelectasis and collapse. The patient
was given Azithromycin and Ceftriaxone for a presumable
pneumonia and was then transferred to the ICU for further
monitoring given his hypoxia and requirement of a
non-rebreather.
.
On ROS, he denies: Fevers, chest pain, cough
Past Medical History:
CAD s/p CABG x4v '[**74**]
CHF EF 30-40%
PVD
DM c/b neuropathy HbgA1c 6.0% 4/09
CVA
Gastritis
Carotid stenosis
HTN
Hyperlipidemia
BPH
Depression
Chronic constipation
T12 compression fracture
Cataract s/p surgery
Glaucoma
Social History:
He grew up in [**State 5887**], has been living inBoston since [**2130**].
He is a veteran of World War II. He worked as a coal miner and
then as a manual laborer. He has been retired for years. He is
widowed and now living with his son. Distant history of smoking
40 years x 2 pack/yr, quit over 20 years ago. No alcohol use.
No drug use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
General Very pleasant obese elderly man, in NAD
HEENT PERRL, EOMI, MMM, OP clear, hearing aids in place
Neck: Supple, no cervical LAD appreciated, JVD to jawline
Pulm: Good respiratory effort, no labored breathing or accessory
muscle use, non-rebreather mask in place. bibasilar crackles
with dullness at the bases bilaterally
CV: Slow, irregular rhythm, nl S1/S2, no extra heart sounds
appreciated
Abd: soft, obese, non-tender, non-distended + BS
Extrem: 1+ bilateral pitting edema to the knees, warm
extremeties
Neuro: AAO x 3, pleasant, cooperative, appropriate affect
Pertinent Results:
[**2193-6-27**] 09:55PM TYPE-ART TEMP-36.7 O2-100 O2 FLOW-10 PO2-31*
PCO2-55* PH-7.37 TOTAL CO2-33* BASE XS-4 AADO2-631 REQ O2-100
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2193-6-27**] 05:37PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2193-6-27**] 05:37PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-NEG
[**2193-6-27**] 05:37PM URINE RBC-2 WBC-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2193-6-27**] 05:37PM URINE HYALINE-4*
[**2193-6-27**] 05:37PM URINE MUCOUS-FEW
[**2193-6-27**] 05:00PM GLUCOSE-136* UREA N-27* CREAT-1.1 SODIUM-142
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-14
[**2193-6-27**] 05:00PM estGFR-Using this
[**2193-6-27**] 05:00PM CK(CPK)-68
[**2193-6-27**] 05:00PM cTropnT-0.02*
[**2193-6-27**] 05:00PM CK-MB-NotDone proBNP-2535*
[**2193-6-27**] 05:00PM WBC-6.8 RBC-4.53* HGB-12.6* HCT-38.7* MCV-86
MCH-27.9 MCHC-32.6 RDW-18.3*
[**2193-6-27**] 05:00PM NEUTS-59.2 LYMPHS-25.8 MONOS-11.3* EOS-2.9
BASOS-0.8
[**2193-6-27**] 05:00PM PLT COUNT-177
[**2193-6-27**] 05:00PM PT-15.1* PTT-29.2 INR(PT)-1.3*
[**2193-6-29**] 06:20AM BLOOD WBC-6.5 RBC-4.00* Hgb-11.4* Hct-33.5*
MCV-84 MCH-28.4 MCHC-33.9 RDW-18.1* Plt Ct-189
[**2193-6-29**] 06:20AM BLOOD Neuts-57.6 Lymphs-26.4 Monos-11.5*
Eos-3.6 Baso-0.9
[**2193-6-29**] 06:20AM BLOOD Plt Ct-189
[**2193-6-29**] 06:20AM BLOOD PT-15.0* PTT-35.5* INR(PT)-1.3*
[**2193-6-29**] 06:20AM BLOOD Glucose-74 UreaN-30* Creat-1.3* Na-140
K-3.6 Cl-100 HCO3-30 AnGap-14
[**2193-6-28**] 05:26AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2193-6-27**] 05:00PM BLOOD cTropnT-0.02*
[**2193-6-27**] 05:00PM BLOOD CK-MB-NotDone proBNP-2535*
[**2193-6-29**] 06:20AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.1
[**2193-6-29**] 06:20AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.1
[**2193-6-27**] 09:55PM BLOOD Type-ART Temp-36.7 FiO2-100 O2 Flow-10
pO2-31* pCO2-55* pH-7.37 calTCO2-33* Base XS-4 AADO2-631 REQ
O2-100 Intubat-NOT INTUBA Comment-NON-REBREA
URINE CULTURE (Final [**2193-6-28**]): NO GROWTH.
ECG: [**6-27**]
Atrial fibrillation with slow ventricular response. Leftward
axis, likely
left anterior fascicular block. Mild non-specific ST-T wave
abnormalities.
Compared to the previous tracing of [**2193-1-1**] the rhythm is now
atrial
fibrillation. The other findings are similar.
CXR: [**6-27**]
IMPRESSION: Substantially increased left pleural effusion, now
moderate, with
a predominantly subpulmonic component. Unchanged smaller right
pleural
effusion.
CTA Chest: [**6-27**]
IMPRESSION:
No evidence of pulmonary embolism or aortic dissection. Moderate
bilateral
pleural effusions, loculated, right more than left, and
associated with
bibasilar areas of atelectasis.
Extensive mediastinal lymph nodes might be reactive, but should
be followed in
three months for documentation of stability/regression.
TTE [**6-28**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is moderate to severe global left ventricular hypokinesis (LVEF
= 30 %). There is no ventricular septal defect. The right
ventricular cavity is dilated with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2193-1-1**], the left ventricular ejection fraction is
further reduced.
CXR [**6-29**]
Cardiomediastinal silhouette is unchanged as well as there is no
change in
bilateral pleural effusions. There is interval improvement in
volume
overload/pulmonary edema. There is no pneumothorax. The right
pleural
effusion loculations are redemonstrated.
Brief Hospital Course:
Mr. [**Known lastname **] is an 82M w CAD s/p CABG, systolic CHF, and pleural
effusions who presents with increasing SOB
HOSPITAL COURSE BY PROBLEMS:
# Acute on Chronic CHF exacerbation- Patient with history of
chronic systolic CHF. In the past has not adhered to lasix due
to concerns regarding urinary incontinence. ABG in ED of
7.35/55/31 while on NRB shows impressive hypoxemia, although per
report from ED staff, at that time, pt's pulse Ox was 100%,
suggestive that sample was likely VBG not ABG. Pneumonia was
considered as cause of dyspnea but pt remained afebrile and low
WBC. CE remained negative w/ trop 0.02. Pt was diuresed with 60
IV lasix and put out 2.5L. The next day she felt significantly
improved. TTE was repeated and showed that the left atrium is
mildly dilated. The right atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is moderate to severe
global left ventricular hypokinesis (LVEF = 30 %). There is no
ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Lasix was increased to 60mg [**Hospital1 **] day prior to discharge.
# Atrial fibrillation- In ED,patient in atrial fibrillation -
rate controlled since admission in the 40-50's. BP stable. A fib
not previously documented and onset now may have been
precipitated by pneumonia. CHADS2 score = 6, therefore he would
be a candidate for anticoagulation as an outpatient. Pt was
started on coumadin 4mg. On discharge INR was 1.2 on discharge.
His coumadin was increased to 5mg. BB was deacreased to due to
bradycardia now Toprol 25 from 100. TSH was also normal. The
patient will have follow-up with coumadin clinic for INR
management.
# Coronaries: 3vd s/p CABG. No active ACS suspected. Continued
ASA, statin, ACEI, BB
# Mediastianal LAD- Extensive mediastinal lymph nodes seen on
CT-scan might be reactive, but should be followed in three
months for documentation of stability/regression.
# Hematuri/[**Name (NI) 30294**] pt says he normally has urinary incontinence and
uses depends. He voided w/o the foley and was discharged without
a foley. Pt's hematuria was either due to the foley or from
anticoagulation. Pt will follow up with urology as outpt.
Medications on Admission:
Amlodipine 10 mg Tablet
1 Tablet(s) by mouth daily
Brimonidine [Alphagan P] 0.15 % Drops
1 gtt(s) OD twice a day (optho)
Citalopram [Celexa] 40 mg Tablet
1 and [**1-18**] Tablet(s) by mouth once a day
Dorzolamide-Timolol [Cosopt]
0.5 %-2 % Drops
1 gtt OD twice a day
Finasteride 5 mg Tablet
1 Tablet(s) by mouth once a day
Furosemide 40 mg Tablet
1 ans [**1-18**] Tablet(s) by mouth daily
Lisinopril 40 mg Tablet
1 Tablet(s) by mouth daily (Dose adjustment - no new Rx)
[**2193-6-27**]
Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
1 Tablet(s) by mouth daily
Pilocarpine HCl [Pilopine HS]
4 % Gel apply OD at bedtime
Risperidone [Risperdal]
1 mg Tablet
1 and [**1-18**] Tablet(s) by mouth at bedtime (
Simvastatin 20 mg Tablet 1 Tablet(s) by mouth once a day for
chol
* OTCs *
Aspirin 81 mg Tablet, Delayed Release (E.C.)
1 Tablet(s) by mouth once a day (OTC)
Insulin NPH Human Recomb [Humulin N]
100 unit/mL Suspension
14 units twice a day
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Fourteen
(14) units Subcutaneous twice a day.
8. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Risperidone 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
12. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
13. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Please check INR on Wednesday [**7-3**], fax results to Dr. [**Name (NI) 47530**] office at [**Telephone/Fax (1) 6443**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] VNA
Discharge Diagnosis:
Primary: Congestive heart failure exacerbation, atrial
fibrillation
Secondary: Type II Diabetes mellitus, Benign Prostatic
Hypertrophy, Depression
Discharge Condition:
stable
Discharge Instructions:
You were found to be having an exacerbation of your congestive
heart failure. We gave you intravenous medication to remove
fluid. We also determined you were in a heart rhythm called
atrial fibrillation which we believe was likely what triggered
your heart failure.
NEW MEDICATIONS:
-Warfarin: this is a blood thinner that you need to take daily.
you will need to have your blood tested regularly to monitor
your INR which is a measure of this drug's effect.
MEDICATION CHANGES:
-Lasix: Increased from 60 mg daily to 60mg twice a day
-Metoprolol: Decreased from 100mg daily to 25mg daily
If you experience chest pain, shortness of breath, difficulty
lying flat or any other concerning symptom please contact your
PCP or come to the emergency department for evaluation. Please
tell Dr. [**Last Name (STitle) **] if you notice any dark or bloody stools, if you
have a cut that won't stop bleeding, if you fall at home or if
you get frequent nosebleeds.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days
Adhere to 2 gm sodium diet
Followup Instructions:
***Please note the following finding on your CT scan: Extensive
mediastinal lymph nodes might be reactive, but should be
followed in three months for documentation of
stability/regression.
Please see a cardiologist for follow up. An appointment has been
made with Dr. [**Last Name (STitle) **] at [**Hospital Ward Name 23**] [**Location (un) 436**]. Friday [**7-5**] at
11:20am
Please follow up with your PCP: [**Name10 (NameIs) **], [**Name11 (NameIs) **] in [**1-18**] weeks. He
will follow your INR and tell you how much coumadin to take.
Please follow up with a urologist for blood in your urine and
urinary incontinence. An appointment has been made for 9am on
[**8-23**] with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] the [**Hospital Ward Name 23**] Building [**Location (un) 470**].
Completed by:[**2193-7-1**]
|
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icd9cm
|
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icd9pcs
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12503, 12558
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7795, 10217
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9,505
| 102,039
|
53463
|
Discharge summary
|
report
|
Admission Date: [**2192-5-25**] Discharge Date: [**2192-5-29**]
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. [**Known lastname 44865**] is a [**Age over 90 **] year-old female with advanced dementia who
presented with respiratory distress, BIBA on bipap, tachypneic
and tachycardic, likely secondary to aspiration event; after
goals of care discussion, patient is now CMO.
By report, patient was being fed by her caretaker, received some
advil and developed respiratory distress with a question of
aspiration. Patient's baseline function nonverbal and they use a
device to mobilize her from bed to chair. Spends day watching
TV, not interactive with people. In the ED it was discussed that
there would be no intubation, no compressions, no
defibrillation, no central line, no pressures. Medications by
vein and BiPap OK. Would not want cath.
Upon EMS arrival, tachypneic to 30-40, received nitropaste and
lasix en route with improvement. SBP 80-90 on arrival. Improved
off of bipap with SBP 140. Was taken off nitro paste in ED. Did
well on CPAP and then on NC, then shovel mask.
Labs significant for lactate 2.7, K 5.3, creatinine 0.9, trop
0.07, BNP 8751. WBC 21.7, Hct 42.4, Plate 493, N 88, band 1. UA
negative
She was given Ceftriaxone 1,250mg, Flagyl 500mg. CXR showed low
lung volumes, no focal consolidation or pleural effusion,
minimal left basilar atelectasis. EKG with ?STE I, avL. Blood
cultures were sent.
On the floor, does not appear to be in pain. She occassionally
tracks with her eyes but is nonverbal. She is not in respiratory
distress.
Past Medical History:
- Advanced dementia, multi-infarct
- Diverticulosis
- Hearing loss
- Retinal detachment
- B12 deficiency
- Chronic abdominal pain
- Irritable bowel syndrome
- Spinal Stenosis
Social History:
She was an English professor for many years. Lives with husband
who is her primary care giver. Had health aides that come to the
house 7 days a week. She has 2 sons. She has profound vascular
dementia, is dependent with all ADLs and is non verbal at
baseline.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM
General Appearance: No acute distress
Eyes / Conjunctiva: R>L pupil, both reactive (baseline)
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear :)
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Skin: Stage V pressure ulcers bilateral calves
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
DISCHARGE EXAM
GEN: no apparent distress
RESP: 14-20, anterior clear to auscultation
CV: RRR, nl S1, S2, no MRG
ABD: soft
EXT: stage V pressure ulcers bilateral posterior calves, R
appears with purulent discharge & foul-smelling odor, bilateral
large toes with ulcers
Pertinent Results:
# LABORATORY DATA
Admission Labs
[**2192-5-25**] 06:00PM BLOOD WBC-21.7* RBC-4.66 Hgb-13.8 Hct-42.4
MCV-91 MCH-29.6 MCHC-32.5 RDW-14.1 Plt Ct-493*
[**2192-5-25**] 06:00PM BLOOD Neuts-88* Bands-1 Lymphs-6* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2192-5-25**] 06:00PM BLOOD PT-11.6 PTT-21.8* INR(PT)-1.0
[**2192-5-25**] 06:00PM BLOOD Glucose-218* UreaN-38* Creat-0.9 Na-135
K-5.3* Cl-97 HCO3-24 AnGap-19
[**2192-5-25**] 06:00PM BLOOD cTropnT-0.07* proBNP-8751*
[**2192-5-25**] 06:15PM BLOOD Lactate-2.7*
Discharge Labs: N/A.
# IMAGING
[**5-25**] CHEST (Portable AP)
SEMI-UPRIGHT AP VIEW OF THE CHEST: The lung volumes are low. The
heart size is mildly enlarged with left ventricular
predominance. The aorta is mildly tortuous and diffusely
calcified. The pulmonary vascularity is normal. There may be
minimal left basilar atelectasis, but no focal consolidation is
seen. No pleural effusion or pneumothorax is present.
Degenerative changes are noted within the imaged thoracolumbar
spine, as well as involving both glenohumeral and
acromioclavicular joints.
IMPRESSION: Minimal left basilar atelectasis.
# MICROBIOLOGY
[**5-25**] Blood cultures: Pending at discharge.
Brief Hospital Course:
[**Age over 90 **] year-old female with advanced dementia who presented with
respiratory distress, likely secondary to aspiration event.
# Goals of care: After multiple conversations the patient's
husband/HCP and son decided that care to prolong life was not
the priority and they would like to focus on comfort.
Antibiotics, lab draws & imaging studies were discontinued and
the patient was made comfort measures only. Palliative care was
consulted and helped the family arrange home hospice.
# Stage V pressure ulcers: Patient has stage V pressure ulcers
on her bilateral posterior calves inferiorly, as well as
bilateral ulcers on her 1st toes. Wound care was consulted and
made recommendations for appropriate wound care. At this point,
surgical debridement of the ulcers is not in line with the
patient's goal of care, which is comfort.
# Leukocytosis: With bands, most likely secondary to occult
infection versus stress response. See 'goals of care' above.
# Elevated troponin: Had been elevated in the past. No
significant EKG changes. See 'goals of care' above.
# Code status: Changed to comfort measures only (CMO) during
this admission.
Medications on Admission:
Aspirin 81 mg daily
Vitamin D 400 U daily
Advil 600 mg daily
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day). Disp:*qs bottle* Refills:*2*
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation. Disp:*20
Suppository(s)* Refills:*1*
3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
[**2-5**] mL PO q1h (every one (1) hour) as needed for pain or
respiratory distress. Disp:*30 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
circle of caring
Discharge Diagnosis:
Primary diagnosis:
# Aspiration pneumonitis
# End-stage dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
# You were admitted to the hospital because you were having
difficulty breathing. You likely aspirated food or a pill (food
went down the wrong way, into your lungs rather than to your
stomach). You were initially taken to the intensive care unit,
but after discussion about goals of care, you were transferred
to the medical floor with comfort care as our primary goal.
# We made the following changes to your medications:
- STARTED morphine solution for pain
- STARTED docusate sodium liquid to soften stool
- STARTED bisacodyl suppositories as needed for constipation
- STOPPED aspirin
- STOPPED Advil (ibuprofen)
- STOPPED vitamin D
# For comfort, you should take morphine 30 minutes prior to your
dressing changes.
# You should take docusate sodium liquid twice a day to soften
your stools. Use the bisacodyl suppository as needed for
constipation.
# Follow up with hospice care as needed.
Followup Instructions:
Follow up with Circle of [**Hospital **] hospice as needed (tel:
[**Telephone/Fax (1) 77096**]).
Completed by:[**2192-5-29**]
|
[
"281.1",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5913, 5960
|
4205, 5358
|
234, 241
|
6068, 6068
|
2998, 3511
|
7127, 7254
|
2218, 2237
|
5469, 5890
|
5981, 5981
|
5384, 5446
|
6203, 6599
|
3527, 4182
|
2252, 2978
|
6628, 7104
|
174, 196
|
269, 1727
|
6000, 6047
|
6083, 6179
|
1749, 1925
|
1941, 2202
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,307
| 148,532
|
45558
|
Discharge summary
|
report
|
Admission Date: [**2120-3-26**] Discharge Date: [**2120-5-10**]
Date of Birth: [**2057-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Paracentesis, Multiple foot debridements
History of Present Illness:
This a 62 yo M with cirrhosis [**3-12**] NASH, hepatorenal syndrome,
and chronic non-healing superinfected RLE wound (VRE and C.
[**Month/Day (2) 563**]) in the setting of various foot/malleolar dislocations
and fractures followed by multiple debridements, initially
admitted for altered mental status, with extended hospital
course complicated by UGI bleed who was transferred to the MICU
for worsening encephalopathy/AMS on [**2120-4-13**].
.
In the MICU, the patient was kept on a NRB with continued
respiratory distress. The patient then acutely decompensated and
failed a trial of noninvasive ventilation, and was ultimately
intubated. The patient had a L IJ hemodialysis line for
emergency dialysis. He had multiple rounds of CVVH. He was
started on levophed for hypotension. CVVH was stopped an HD was
initiated. The patient mental status was treated with lactulose.
He also became febrile so zosyn was stopped and meropenem was
started for a time. He is currently on
daptomycin/meropenem/micafungin. The patient mental status
improved and he was successfully extubated. He was also weaned
from levophed and was tolerating HD well. He went to the OR for
right leg washout on [**2120-4-15**]. He is currently on q3day vac
changes. ID followed the patient while in the ICU, and
recommended a 6 week course of abx after the last orthopedics
intervention. His mental status remained clear and he was
hemodynamically stable. He was transferred to the floor.
Past Medical History:
1. Cirrhosis likely due to Steatohepatitis, followed by Dr.
[**First Name (STitle) 679**]. Last tap [**2120-3-19**]. States he gets tapped q10days.
2. Irritable Bowel Syndrome
3. Type 2 Diabetes Mellitus with extreme insulin resistence
4. Gastroparesis
5. Obesity
6. Hyperlipidemia
7. Rheumatoid Arthritis
8. Depression
9. Chronic Renal Insufficiency baseline Cr 2.6 over the last
year
[**20**]. Obstructive Sleep Apnea on CPAP
11. HTN
12. ORIF Right ankle
Social History:
Occupation: Has PhD in Psychology-retired Mass DMH psychologist.
No tobacco, no ETOH, no other drugs.
Family History:
No h/o clotting disorders. Mother died of PNA in 80s, also had
thyroid disease. Father died of heart disease in 70's, had
cancer (unknown type), tobacco and alcohol abuse. Family h/o
T2DM.
Physical Exam:
VS: 99.4 105 114/58 20 95% on RA
GA: jaundiced M lying in bed, AOx1 (to name only), NAD
HEENT: PERRLA. MM dry. no LAD. icteric sclera. no JVD. neck
supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: crackles at bases
Abd: soft, distended/protuberant with +fluid wave. NT, +BS. no
g/rt. liver edge non-palpable.
Extremities: hardware supporting RLE cellulitis with wound vac.
DPs, PTs 1+ BL.
Pertinent Results:
ADMISSION LABS:
[**2120-3-26**] 05:00AM WBC-5.1 RBC-3.36* HGB-9.5* HCT-29.6* MCV-88
MCH-28.2 MCHC-32.0 RDW-16.8*
[**2120-3-26**] 05:00AM NEUTS-81.0* LYMPHS-12.5* MONOS-3.8 EOS-2.5
BASOS-0.2
[**2120-3-26**] 05:00AM ALBUMIN-3.2* CALCIUM-8.9 PHOSPHATE-5.5*
MAGNESIUM-2.9*
[**2120-3-26**] 05:00AM GLUCOSE-54* UREA N-78* CREAT-3.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-20* ANION GAP-18
[**2120-3-26**] 05:00AM ALT(SGPT)-20 AST(SGOT)-45* CK(CPK)-82 ALK
PHOS-132* TOT BILI-0.8
[**2120-3-26**] 05:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2120-3-26**] 05:25AM URINE RBC-0 WBC-[**4-12**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2120-3-26**] 05:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-3-26**] 01:58PM PT-17.4* PTT-114.2* INR(PT)-1.6*
-----------------
DISCHARGE LABS:
[**2120-5-10**] 05:40AM BLOOD WBC-6.4 RBC-3.15* Hgb-9.1* Hct-30.3*
MCV-96 MCH-28.8 MCHC-29.9* RDW-18.3* Plt Ct-165
[**2120-5-10**] 05:40AM BLOOD PT-17.6* PTT-30.7 INR(PT)-1.6*
[**2120-5-10**] 05:40AM BLOOD Glucose-82 UreaN-42* Creat-4.7*# Na-139
K-4.5 Cl-99 HCO3-27 AnGap-18
[**2120-5-10**] 05:40AM BLOOD ALT-50* AST-157* AlkPhos-284*
TotBili-2.7*
[**2120-5-10**] 05:40AM BLOOD Calcium-8.4 Phos-7.4*# Mg-2.8*
-----------------
MICROBIOLOGY:
blood cx's ([**Date range (1) 97168**]) - ngtd
stool cx's - c. diff neg x3
sputum cx's ([**4-17**])
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R 16 I
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- =>64 R R
CEFTAZIDIME----------- R R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
R ankle wound swab - ([**4-8**], [**4-15**]) VRE and C. [**Month/Day (4) 563**]
.
Urine cultures - yeast contaminants ([**4-3**], [**4-6**], [**4-7**])
-----------------
STUDIES:
[**2120-3-26**] EKG: Sinus rhythm. Slight intraventricular conduction
delay with left axis deviation may be due to left anterior
fascicular block. Since the previous tracing of the same date no
significant change.
.
[**2120-3-26**] CXR: IMPRESSION: Silhouette of the left heart border,
could reflect a lingular atelectasis or consolidation. A lateral
view, if clinically feasible, would be helpful in further
characterization.
.
[**2120-3-26**] LENI: IMPRESSION: No DVT in bilateral lower extremities.
.
[**2120-3-29**] Liver US: IMPRESSION: 1. Nodular hepatic architecture
with no focal liver lesion identified. 2. Patent hepatic
vasculature. 3. Splenomegaly. 4. Large amount of ascites.
.
[**2120-4-16**] TTE: The left atrium is markedly 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 normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. IMPRESSION: Mild symmetric left
ventricular hypertrophy with preserved global
biventricularsystolic function.
.
[**2120-4-26**] CXR: As compared to the previous examination, there is
no relevant change. Small lung volumes, bilateral areas of
atelectasis, but no evidence of focal parenchymal opacity
suggesting pneumonia. Unchanged course of the nasogastric tube
and of the right double-lumen catheter. Borderline size of the
cardiac silhouette.
Brief Hospital Course:
62-year-old male with history of DM on insulin, [**Month/Day/Year 2091**], R ORIF with
Ex-Fix in place who presents from rehab with altered mental
status and low sugar.
.
# Right lower extremity infection: The patient has a chronic
right lower extremity cellulitis and osteomyelitis secondary to
a traumatic R tibiotalar posterior dislocation and open
trimalleolar fracture s/p external fixation [**2120-3-7**]. He is s/p
multiple debridements and revisions with non healing R ankle
wound. Cultures from the infection include VRE and [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 563**]. He is being treated with antibiotics including
daptomycin and micafungin. Daptomycin and micafungin are to
continue for 6 weeks after last last debridement. The last day
of antibiotics will be [**2120-5-26**]. Pt has a vac dressing in place,
which needs to be changed q3d.
.
# Altered mental status: The patient has multiple etiologies of
his altered mental status. He presented with renal failure,
decompensated cirrhosis, LE infection. He was treated with
antibiotics for the leg infection. His renal failure eventually
required hemodialysis. His hepatic encephalopathy was treated
with lactulose and rifaximin. His mental status improved at the
time of discharge. He was alert, oriented to place and person,
and thought the year was [**2122**].
.
# ESRD: The patient had renal failure that was most consistent
with hepatorenal syndrome. He was started on midodrine,
octreotide and albumin. This however failed and he required
hemodialysis. He is now considered to have ESRD dependent on HD
and is currently anuric. Midodrine is continued for hypotension
but octreotide is no longer needed.
.
# Cirrhosis: The patient has decompensated cirrhosis. He has
hepatic encephalopathy on lactulose and rifaximin. He had a
variceal bleed requiring EGD and banding. He will need to get a
repeat EGD as an outpatient. He was continued on nadolol. He has
ascites and was continued on paracentesis with albumin
replacement afterwards. His nutrition was initially given
through NGT when he was delirious. Patient passed speech and
swallow, and was given regular POs on the day of discharge. He
was able to tolerate POs.
.
# Anemia: The patient had variceal bleed. He had an EGD and is
s/p variceal banding and gluing. His hct has been stable during
the rest of his hospital stay.
.
# GIB: Pt developed melena on HD 2 with associated HCT drop. He
was started on a PPI, had large bore PIV access established. He
was transfused without appropriate HCT bump and was taken for
EGD/Sigmoidoscopy. The sigmoidoscopy was without source of
bleeding. The EGD showed esophageal and gastric varices, with
blood clot in the stomach without obvious active bleeding. He
went for a second EGD on [**3-29**] and had banding/glueing of his
varices. Subsequent to the banding he was given one additional
unit and his HCT remained stable. On the night of [**5-7**], the
nurse [**First Name (Titles) **] [**Last Name (Titles) 97169**] NG to assess for TF residual when
coffee-ground material was noted. A 600cc lavage demonstrated
blood clots mixed with blood tinged fluid. Patient was
transferred to MICU overnight, and was observed for approx. 24
hours. His hct was stable, and he was hemodynamically stable.
Patient was transferred back to the floor, and had no more
episodes of GIB.
.
# Thrombocytopenia. Platelets trended down since admission.
This may be a function of spelnic sequestration, recent GIB and
surgery vs. HIT. HIT unlikely given timing, degree of platelet
drop and other factors that are more likely. Platelet count
stablized and improved over his hospital stay.
.
# CP/SOB: Pt had complained of CP/SOB on arrival to the
Emergency Department. There were no EKG changes but his
troponin was 0.12 in the setting of chronic renal insufficiency.
This may represent lack of clearance [**3-12**] CRI, NSTEMI, or strain
from PE. A PE protocol CT was not performed due to concern over
his renal function. His CEs were flat and there were no EKG
changes. Bilateral LENI were negative for DVT. He r/o for ACS
and his Heparin gtt was stopped. He has had no complaints of CP
or SOB since his initial presentation to the ED.
.
# Respiratory failure: The patient aspirated and developed
hypoxemic respiratory failure. He was intubated. He was
continued on dapto, meropenem and micafungin. He was groing
E.Coli in his sputum. He was able to be weaned and extubated
without difficulty.
.
# Diabetes mellitus: Patient was on glargine and humalog sliding
scale, and his blood sugar was well-controlled during this
hospital stay.
.
# Hypotension: Patient's blood pressure was low (sbp in the 80s
and 90s) during this hospital stay. Patient was on nadolol for
varices prophylaxis, and we held metoprolol and amlodipine. He
was started on midodrine 10mg TID.
.
# Obstructive sleep apnea: Patient was on BiPAP overnight during
this hospital stay.
.
# Rheumatoid arthritis: Not on home medications. No acute
treatment needed currently.
.
# Depression: Patient was continued on escitalopram and
bupropion.
Medications on Admission:
1. Amlodipine 10 mg
2. BuPROPion (Sustained Release)200 mg [**Hospital1 **]
3. Calcium Carbonate 1000 mg po qd
4. Docusate Sodium 100 mg [**Hospital1 **]
5. Escitalopram Oxalate 10 mg qd
6. FoLIC Acid 1 mg qd
7. Furosemide 80 mg qd
8. HYDROmorphone (Dilaudid) 2 mg q4hrs prnl 4 mg q 4 hrs for
severe pain
9. Humulin R U-500 17 units breakfast; 13 units lunch; 15-20
units at dinner; on SS
10. Lactulose
11. Metoprolol Tartrate 25 mg [**2-10**] tab [**Hospital1 **]
12. Pantoprazole 40 mg [**Hospital1 **]
13. Rifaximin 200 mg tid
14. Senna
15. Spironolactone 25 mg [**Hospital1 **]
16. TraMADOL (Ultram) 50 mg qhs
17. Vitamin D 400 u 2 tabs qd
18. fenofibrate 145 mg 1 tablet qd
19. Aranesp 50 mcq/ml q week
20. vancomycin 750 mg IV for 4 weeks.
21. ascorbic acid 500 mg [**Hospital1 **]
22. ampicillin/sulbactam 3 gm q hrs for 4 weeks
23. iron SR 325 mg qd
24. acidophilis 1 cap [**Hospital1 **]
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
4. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. Sodium Citrate Solution Sig: 1.4 MLs PO ASDIR (AS
DIRECTED) as needed for catheter not in use: Sodium CITRATE 4%
1.4 mL DWELL ASDIR catheter not in use
Renal fellow to specify volume to instill for catheter dwell. .
7. Heparin (Porcine) 1,000 unit/mL Solution Sig: see instruction
Injection PRN (as needed) as needed for line flush: Heparin
Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush
Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS
NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS
followed by Heparin as above according to volume per lumen. .
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: please do not give> 2g per day
.
10. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day): titrate to [**4-11**] loose BMS daily (not watery). this
is for hepatic encephalopathy NOT just simple constipation.
11. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
13. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
15. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Eight (8) MG
Injection Q8H (every 8 hours) as needed for nausea.
17. Micafungin 100 mg Recon Soln Sig: One Hundred (100) MG
Intravenous Q24H (every 24 hours): last day [**2120-5-26**].
18. Daptomycin 500 mg Recon Soln Sig: Nine Hundred (900) mg
Intravenous Q48H (every 48 hours): last day [**5-26**].
19. Dextrose 50% in Water (D50W) Parenteral Solution Sig:
12.5 gm Intravenous PRN (as needed) as needed for hypoglycemia
protocol.
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
21. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: Heparin
Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
.
22. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
23. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush:
Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN. .
24. Insulin Glargine 100 unit/mL Cartridge Sig: Fifty (50) unit
Subcutaneous at bedtime.
25. Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS: please see the attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
- cirrhosis
- hepatic encephalopathy
- hepatorenal syndrome
- ESRD on HD
- right ankle fracture dislocation s/p 6 OR procedures since [**Month (only) **]
[**2120**], 5 of the 6 procedures during this admission
- GIB
- Hypotension
.
Secondary diagnoses:
- DM
- Anemia
- OSA
- RA
- Depression
Discharge Condition:
Mental Status: Confused - sometimes, alert and oriented to place
and person, thinks the year is '[**2122**]'
Level of Consciousness: Alert and interactive
Activity Status: Bedbound
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname **]. You
were initially admitted to [**Hospital1 69**]
because of altered mental status, and you had a prolonged
hospital course complicated by GI bleed, respiratory failure,
hepatorenal syndrome resulting in end-stage renal disease
requiring hemodialysis, and waxing and [**Doctor Last Name 688**] mental status due
to liver cirrhosis and ankle infections. You were taken to OR 5
times during this hospital stay for irrigation, debridement,
repair, and antibiotic bead placement and removal in your right
ankle fracture wound. The last OR procedure was on [**2120-4-15**] when
vacuum sponge was placed. You were treated with antibiotics.
You were followed by the liver team who felt that you are not a
transplant candidate. Your kidney had failed, and you were
started on hemodialysis. You will most likely need life-long
dialysis. On the day of discharge, your mental status has
improved and stabilized. You passed speech and swallow test and
you wer given regular food to eat. Your nasogastric feeding
tube was removed on the day of discharge.
.
Your medications have been changed after this prolonged hospital
stay. The medication list will be given to the acute care
facility which will continue to take care of you after you are
discharged from [**Hospital1 18**].
Followup Instructions:
Please have hemodialysis sessions as instructed.
.
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: [**Last Name (LF) 766**], [**5-20**], 1:45pm
.
Department: ORTHOPEDICS
When: TUESDAY [**2120-5-21**] at 2:10 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ORTHOPEDICS
When: TUESDAY [**2120-5-21**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: [**Last Name (LF) 2974**], [**5-24**], 2pm
.
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2120-5-29**] at 11:10 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Please follow up with your primary care doctor within 3 days
after discharge from rehab.
|
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|
2366, 2470
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,487
| 157,318
|
5657
|
Discharge summary
|
report
|
Admission Date: [**2134-4-4**] Discharge Date: [**2134-4-9**]
Date of Birth: [**2069-10-19**] Sex: M
Service: MEDICINE
Allergies:
Betadine / Adhesive Tape / Percocet
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
GI bleeding, VF arrest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 yo male with esophageal cancer s/p XRT, on chemo, presented
to the ED with complaint of coffee-ground emesis 3x over the
past 2 days. He had last chemo dose on Monday and had a week of
his usual post-chemo fatigue. He had significant epistaxis the
night prior to vomiting that required packing. Also complained
of diarrhea, but denies melena. Had complained of some abdominal
pain. He did endorse lightheadedness and dizziness. Throughtout
ED course, compained of abdominal pain, and wife noted he had
some ectopy on his tele. He denied any chest pain, shortness of
breath, or palpatations.
Approx 5 hours after arriving in the ED, patient developed
V-tach that progressed to V-fib per patient's wife and [**Name (NI) **]
attending note. Vitals had been stable until that time except
for a temp of 101.7. Patient was shocked at 200 and returned to
paced (baseline) rhythm, pulse returned. He was breathing
spontaneously, but was intubated for airway protection. OG tube
placed, no red blood on lavage, no coffee-grounds were noted.
Patient was fighting the tube, and was sedated. Patient was
dosed with protonix, cefepime, vancomycin. Lidocaine gtt was
started. Norepinephrine started for BP support.
.
Of note, patient had been using MagicMouth for esophageal
discomfort. He was more fatigued, but this was normal for his
chemo. The epistaxis was also not atypical. Recently, his ace
and BB were discontinued.
.
Past Medical History:
COPD/ pulmonary fibrosis
HTN
DM2 neuropathy, nephropathy
Barrett's esophagus and GERD, recently (in [**October 2133**]) diagnosed
with esophageal CA s/p XRT being treated now with 5-FU and
CPT-11;
AVR in [**2133**]. [**Male First Name (un) 1525**] mechanical valve
CAD s/p 2v-CABG [**19**]
PPM placed for AF (previously treated on amiodarone-
discontinued because of concerns pulmonary fibrosis from
amiodarone) S/P AVJ ablation for atrial fibrillation; VVI
electronic Sigma Pacemaker; congestive heart failure [**2-18**]
diastolic dysfunction (EF 35%); Strongyloides resulting in
eosinophilia and dyspnea, hypothyroid, left renal artery
stenosis, htn, hypercholesterol, CRI (baseline Cr 2.8-3.4)
Social History:
Married. Now on diasbility, previous work as a corporate artist,
worked in textiles, cloth books. Worked with textile
manufacturors (inhalation exposure to formaldehyde used in
textile processing). No ETOH use. Smoking history, quit [**2119**], 25
pack year history. Son [**Name (NI) 9168**], wife nurse.
Family History:
NC
Physical Exam:
Vitals: T 101 70 93/39 sat 100%
on AC 550/16/100%/5
Gen: sedated, intubated, pale, comfortable, family at bedside,
patient can open eyes slightly to his name
HEENT: mmm, OG tube and ET tube in place, prrl, neck is supple,
CV: rrr, S1 loud mechanical S2 2/6 SEM
Pulm: clear bilat
Abd: thin, soft, non-distended, prior surgical scar noted
Ext: no edema, warm and well perfused
Pertinent Results:
[**2134-4-4**] 02:35PM GRAN CT-1260*
[**2134-4-4**] 02:35PM PT-31.6* PTT-31.8 INR(PT)-3.4*
[**2134-4-4**] 02:35PM NEUTS-79* BANDS-1 LYMPHS-7* MONOS-6 EOS-7*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2134-4-4**] 02:35PM WBC-1.7* RBC-3.03* HGB-9.4* HCT-28.9* MCV-95
MCH-30.9 MCHC-32.4 RDW-21.7*
[**2134-4-4**] 02:35PM GLUCOSE-177* UREA N-40* CREAT-1.7* SODIUM-143
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-18
[**2134-4-4**] 08:10PM GRAN CT-890*
[**2134-4-4**] 08:10PM WBC-1.4* RBC-3.10* HGB-9.6* HCT-29.7* MCV-96
MCH-31.1 MCHC-32.5 RDW-21.9*
[**2134-4-4**] 08:10PM ALBUMIN-3.9 CALCIUM-8.6 PHOSPHATE-2.3*
MAGNESIUM-1.7
[**2134-4-4**] 08:10PM CK-MB-NotDone cTropnT-<0.01
[**2134-4-4**] 08:16PM LACTATE-3.0*
.
Echo [**2133-12-15**]:
LV EF 35% mod dilated LV,
RV: dilated RV, depressed fxn. TR gradient 50
Valves: 2+MR, 2+TR, traace AR
CXR: : A left-sided pacemaker is seen with lead in unchanged
position. The patient is status post CABG and median sternotomy
wires are visualized. A right-sided subclavian catheter
terminates in the cavoatrial junction. The cardiomediastinal
silhouette is stable with a large left atrial shadow. Again
noted is left-sided pleural thickening and adjacent parenchymal
scarring. There is no evidence of pneumothorax. The right lung
is clear. There is a small left pleural effusion. There is no
evidence of free air underneath the hemidiaphragms.
.
KUB: Air is noted in the rectum and sigmoid colon. There is no
evidence of acute obstruction. Surgical clips are noted in the
left groin. The osseous structures are unremarkable.
.
Brief Hospital Course:
64 yo male with esophageal cancer, one week after his last
chemo, who presented with coffee-grounds emesis after having
significant epistaxis requiring packing. While in the ED,
patient had a VT/VF arrest that resolved after one shock, and
remained hypotensive thereafter.
1. VT/VF arrest:
The pt was found in the ED to be unresponsive with a rapid heart
rhythm that was assessed by the ED physicians to be V-tach vs
VF. There were no ECG rhythm strips recorded for review. The pt
was cardioverted, and he rapidly regained awareness. Patient is
at risk for VT/VF with his hx of CHF as well as prior CAD. He
was started on a lidocaine drip at 30ug/kg per min for
suppression of VT, which was continued on arrival to the [**Hospital Unit Name 153**].
The pt was evaluated by cardiology in the ED who agreed that he
had a possible episode of VF and that lido vs amio could be
continued initially. Given that there were no recurrent events,
lidocaine was discontinued on the following day. It was likely
that sepsis was the precipitating event. EP consulted, and they
recommended starting on amiodarone. This was discussed with Dr.
[**Last Name (STitle) **], the patient's cardiologist. The patient tolerated
amiodarone loading, and he had no further events on telemetry.
2. Septic Shock:
Patient bordering on neutropenia. Pt was febrile to 102 in ED,
with increased neutrophil predominance, immunosuppressed, and
ANC ~600. His lactate level was 3.0 (after VF and shock). He was
pan-cultured, started on vanc/cefepime, and arrived to the [**Hospital Unit Name 153**]
on levophed in addition to the lidocaine drip. He was weaned
off pressors quickly, and all culture data were negative with
the exception of sputum gram stain which showed 4+GNR, 4+GPC.
His antibiotics were changed to cefpodoxime to complete a 14 day
course for a likely respiratory infection.
3. Respiratory Failure: Intubated for airway protection, and
weaned from supplemental O2 prior to discharge.
4. GI bleed/hematemesis: Likely this was from large epistaxis
the night prior to presentation and did not represent GI bleed.
However, he is at risk for bleed given esophageal cancer/xrt. OG
tube had a negative lavage, no sign of melena. Vitals were
stable on presentation to ED for the first 5 hours. Hct trended
down from ~30 to 23.3 during his hospital course, and he was
guaiac positive, though he had no gross blood loss since ICU
admission. INR was 5.3, and he was reversed with 3 U FFP and
transfused 2U pRBC in setting of CAD and recent VT event. His
Hct stabilized, and coumadin was restarted.
5. CHF EF 35%: Pt was recently taken off ACE and BB as
outpatient because bp was too tenuous. He was diuresed with
transfusions.
6. CAD s/p CABG: He had no current evidence of active ischemia,
and ruled out by enzymes. Aspirin not given due to low platelet
counts, and statin started. He will follow up with Dr.
[**Last Name (STitle) **], who is aware of these issues.
7. Esophageal cancer: Last cpt dose was one week prior to
presentation. Follows with Dr. [**Last Name (STitle) 3274**].
8. CRI: Baseline cr 1.7; continued epo.
9. Diabetes: NPH 9u Qam, RISS.
10. Aortic valve replacement: Pt has St. Jude's valve with high
risk for clot and requiring anti-coagulation. INR elevated, and
he was reversed with FFP. Restarted coumadin for goal INR >2.5.
11. AF: s/p AV node ablation, VVI ppm placement.
12. Hypothyroid: continued synthroid
13. FEN: diabetic, cardiac diet, replete K for goal >4 and Mg >2
14. proph: pneumoboots, [**Hospital1 **] PPI
Full Code
Medications on Admission:
Insulin SS
Fent patch 25 mcg/hr q 72h
Prednisone 40mg daily
Pantoprazole 40mg daily
Metoprolol 12.5mg [**Hospital1 **]
Atorvastatin 40mg daily
Allopurinol 300 daily
Tamsulosin 0.4mg qhs
Levothyroxine 75 mcg daily
Epo 20,000 units sq qM,W,F
Colace 100mg [**Hospital1 **]
Bisacodyl prn
Vancomycin 750mg IV q12h
Cefepime 2g IV q12h
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
3. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight
(8) units Subcutaneous qAM.
9. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*100 mg* Refills:*0*
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*100 ML(s)* Refills:*0*
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: after you complete 2 days of 10mg doses.
Disp:*2 Tablet(s)* Refills:*0*
13. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
15. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
16. 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*
17. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Vfib/VT
febrile neutropenia
CAD s/p CABG
.
Secondary:
AVR s/p St. Jude's valve
PPM for afib
VVI electronic sigma pacemaker
COPD
hypertension
DM2
GERD
CRI
hypercholesterolemia
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] or [**Doctor Last Name 3274**] if you have fever, chills,
increasing esophageal pain, nausea, vomiting, shortness of
breath, chest pain, palpitations, diarrhea or any other
discomfort.
.
Please keep the appointments that have been scheduled for you -
the details are provided below.
.
Note the medications that have been changed during this
admission:
- amiodarone 400mg twice a day for the next two weeks, then take
400mg once a day thereafter.
- please restart the atorvastatin at 40mg per day; he will
discuss issues of toprol, lisinopril, and aspirin. You should be
on toprol and lisinopril, but your blood pressure will not
tolerate this presently. Also, aspirin would be beneficial, but
platelet count was low (140). Dr. [**Last Name (STitle) **] aware and agrees
with the above.
- the prednisone should be tapered in the next several days:
take 10mg daily for 2 days, then 5mg for 2 days.
- restart coumadin at 5mg daily - you should have your INR and
CBC checked on Monday [**4-12**] at your appointment with Dr.
[**Last Name (STitle) 3274**].
- please continue to take cefpodoxime for the next 10 days for
possible lung infection.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 15108**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-4-12**] 10:30
Provider: [**Name10 (NameIs) 17515**] CHAIR 1A Date/Time:[**2134-4-12**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-4-12**] 11:00
Dr. [**Last Name (STitle) **]: [**4-13**] at 2:30pm [**Telephone/Fax (1) 6197**]
Dr. [**Last Name (STitle) **]: [**5-10**] at 2:10pm [**Telephone/Fax (1) 612**]
.
You will need to follow up with electrophysiology physicians
when your chemotherapy is complete. Dr.[**Name (NI) 15020**] office can
assist w/ setting this up for you.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2134-6-29**]
|
[
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"401.9",
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"357.2",
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"427.1",
"V58.61",
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"250.60",
"496",
"196.0",
"150.5",
"272.0",
"V43.3",
"530.81",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.07",
"96.04",
"99.62",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10638, 10644
|
4851, 8405
|
318, 324
|
10872, 10881
|
3247, 4828
|
12111, 12956
|
2831, 2835
|
8785, 10615
|
10665, 10851
|
8431, 8762
|
10905, 12088
|
2850, 3228
|
256, 280
|
352, 1770
|
1792, 2491
|
2507, 2815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,857
| 141,720
|
11555
|
Discharge summary
|
report
|
Admission Date: [**2117-2-9**] Date: [**2117-2-26**]
Date of Birth: [**2112-8-15**] Sex: F
Surgeon: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 36763**]
CHIEF COMPLAINT: Nausea, vomiting, abdominal distention.
HISTORY OF THE PRESENT ILLNESS: The patient is a 74-year-old
female with complicated past medical history significant for
squamous cell lung cancer status post left upper lobe
resection in [**2115**], multiple pneumonia, ischemic colitis. The
patient presents with nausea, vomiting, and abdominal
distention. The patient has been discontinued to
rehabilitation late in [**Month (only) 956**], [**2116**] on TPN and NPO with
exception to medications due to ischemic colitis for which
the patient needs elective hemicolectomy.
At the rehabilitation, she has been gradually weaned from the
ventilator, but had recent fever spikes and the sputum grew
Methicillin resistant Staphylococcus aureus and Klebsiella.
These were treated with Cefotetan and Vancomycin with mild
improvement, however, the patient spiked a fever and at this
time she only grew out Klebsiella in her sputum. She was
started on Imipenem for her Klebsiella pneumonia. The PIC
line was discontinued. Once her blood cultures grew [**Female First Name (un) 564**],
at that time she was started on Fluconazole with
surveillance. Blood culture were negative per report of the
rehabilitation. Over the last few days, prior to the
admission, the patient required increased ventilatory
support, and she was restarted assist control 500/20. Over
the last three to four days, the patient had increasing
abdominal distention. She was complaining of nausea and had
bilious emesis. Per husband's report, vomiting had stopped
approximately two days ago. The NG tube was placed on
suction and the abdominal x-ray showed dilated loops of small
bowel and air fluid levels.
On admission, the patient denied abdominal pain, and nausea.
On arrival, she had a moderate-sized, green bowel movement
guaiac-positive.
PAST MEDICAL HISTORY:
1. Squamous cell lung cancer diagnosed in [**8-24**], status post
left upper lobe resection on [**9-24**].
2. Multiple pneumonias with Pseudomonas klebsiella and
Methicillin resistant Staphylococcus aureus.
3. Status post tracheostomy on [**10-24**].
4. History of CMV colitis, status post Ganciclovir
treatment.
5. Recurrent C. difficile colitis.
6. Ischemic colitis.
7. Lower GI bleed.
8. History of partial small bowel obstruction.
9. History of coronary artery disease status post
catheterization with three-vessel disease and stenting times
two.
10. Status post non-Q-wave MI in [**8-24**].
11. Intermittent atrial fibrillation.
12. Hypertension.
13. Clot in the pulmonary vein, pouch-the patient is not
currently on anticoagulation.
14. Asthma and chronic obstructive pulmonary disease.
15. Hypothyroid.
16. Breast cancer status post right mastectomy.
17. Heparin-induced thrombocytopenia.
18. History of diverticulectomy 22 years ago.
ALLERGIES: ? HIT, question benzodiazepine sensitivity.
MEDICATIONS ON ADMISSION:
1. Captopril 50 mg q.8h.
2. Diltiazem 30 mg q.6h.
3. Protonix 40 mg IV q.d.
4. Fluconazole 400 mg IV q.d.
5. Combivent 4 puffs q.i.d..
6. Lasix 40 mg IV q.d.
7. Imipenem 500 mg IV q.6h.
8. Metoprolol 25 mg q.12.
9. Solu-Medrol 4 puffs q.12.
10. Insulin sliding scale.
11. Tamoxifen 20 mg q.d.
12. Levothyroxine 0.075 mg q.d.
13. Aspirin 81 mg q.d.
14. Amiodarone 200 mg q.d.
15. Paroxetine 20 mg p.o.q.d.
16. Fluticasone 220 mEq b.i.d.
FAMILY HISTORY: Mother deceased with CVA, father died of MI,
question of history of COPD.
SOCIAL HISTORY: The patient is married. The patient has a
20 pack per year smoking history; quit 20 years ago. Former
social drinker. The patient's husband is her health-care
proxy.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 101.2, blood pressure 132/54, pulse 66,
respiratory rate 20, oxygen saturation 98% on assist control
500 x 20; PEEP of 5 and FIO2 40%. GENERAL: The patient is
awake, trached, alert, and in no apparent distress. HEENT:
Right pupil is approximately 5-mm. Left pupil is appropriate
2-mm. They are both sluggish to react. Oropharynx with
upper dentures, clean and moist with poor lower dentition.
NECK: JVD difficult to assess, trach intact. CHEST:
Inspiratory wheezes bilaterally, coarse at lower base.
HEART: Regular rate and rhythm, S1 and S2, no murmur, rub,
or gallop. ABDOMEN: Soft, but distended with good bowel
sounds, nontender, no guarding or rebound. Stool is green,
guaiac-positive stool. EXTREMITIES: No clubbing, cyanosis
or edema with difficult to palpate distal pulses.
NEUROLOGICAL: The patient is awake, alert, and follows
commands. She answers yes or no questions appropriately.
She moves all four extremities with strength being 5 out of 5
in all four extremities.
LABORATORY DATA: Findings on admission revealed the white
count of 5.1, hematocrit 27.7, platelet count 176,000,
differential on the white count 67 neutrophils, 26 lymphs, 5
Monocytes, 0.6 eosinophils. Sodium 135, potassium 4.3,
chloride 92, bicarbonate 34, BUN 35, creatinine 1.0, glucose
68, calcium 8.1, magnesium 2.1, phosphate 4.4, albumin 2.3,
ALT 10, AST 25, alkaline phosphatase 53, total bilirubin 0.5.
Chest x-ray revealed probable left pleural effusion, left
sided mild improvement compared with prior film of 220.
Opacification of the left hemithorax, shift of mediastinum to
the left. There was a slight right sided effusion. PIC line
was placed.
KUB: NG tube in stomach. Dilated loops of bowel mainly on
the left side, however, air is seen throughout to the rectum.
ABG on admission 7.57/40/128.
HOSPITAL COURSE: In summary, the patient is a 74-year-old
female with complicated past medical history including
squamous cell lung cancer, status post left upper lobe
resection, ischemic colitis, CMV colitis, multiple
pneumonias, coronary artery disease, presenting with three to
four days of nausea and vomiting abdominal distention, as
well as fungemia with [**Female First Name (un) 564**].
Issues during this hospitalization included the following:
#1. INFECTIOUS DISEASE: The patient has history of fungemia
with [**Female First Name (un) 564**], which was treated with Fluconazole. During
this hospitalization, the patient's blood was found to be
positive for [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] and the patient was started on
Amphotericin B on [**2-12**]. She is to receive 28 days of
Amphotercin B. In addition, the patient was found to be
bacteremia with Staphylococcus, coagulase negative, which was
resistant to Methicillin, but sensitive to Vancomycin. The
patient completed a seven-day course of Vancomycin.
Transesophageal echocardiogram was obtained, which showed no
vegetations and a good ejection fraction. She had
ophthalmological examination of her eyes, with no evidence of
Candidal ophthalmitis.
In addition, the patient underwent CT scan of her abdomen,
which did not reveal any abscesses or localized source of
infection.
#2. GI: The patient presented with nausea, vomiting,
abdominal distention, suggestive of small-bowel obstruction
base on her abdominal film showing gas all the way through to
the rectum. She was judged to have partial small-bowel
obstruction. The NG tube was placed to suction. Over the
course of her hospitalization the NG tube output has been
progressively decreasing. She underwent colonoscopy, which
revealed stricture at 25 cm from her rectum. CT scan of her
abdomen was obtained, which had no evidence of small-bowel
obstruction or ischemic colitis. The Department of Surgery
followed the patient throughout the hospital and did not
think that she would be a good candidate for the elective
left-sided hemicolectomy for her history of ischemic bowel.
#3. PULMONARY: On admission, the patient was ventilating
well on assist control. However, following a seizure on
[**2-12**], she became increasingly difficult to ventilate and
required sedation with Propofol for good ventilation. She
required CPAP with pressor support of 26, which allowed her
to pull tidal volumes of approximately 500, PEEP of 7.5, FIO2
of 40%.
Over the course of a few days, the patient's Propofol was
weaned off and her pressure support was weaned from 26 to 16.
#4. CARDIOVASCULAR: On admission, she was in normal sinus
rhythm and maintain this rhythm throughout the
hospitalization. She was continued on the Amiodarone once
the NG tube output decreased.
#5. NEUROLOGICAL: On [**2-12**], the patient had
generalized tonoclonic seizure. The blood gases, drawn at
that time, showed an acute respiratory acidosis. The patient
was loaded with Ativan, as well as Dilantin with resolution
of her seizures. She was continued on her Dilantin
throughout the hospitalization. She had another seizure on
[**2-15**], at which time the Dilantin was subtherapeutic.
With her first seizures, the patient underwent a head CT
scan, which did not show any hemorrhage or new stroke. She
does have some periventricular white matter disease
indicative of prior strokes. An EEG was obtained, which did
not reveal any epileptiform activity, however, it showed
generalized slowing, indicative of severe encephalopathy.
Neurological consultation was obtained and followed the
patient with the rest of her hospitalization.
#6. HEMATOLOGY: Throughout this hospitalization the patient
had guaiac-positive stools and intermittently required
transfusion when the hematocrit dipped below 30.
#7. FLUIDS, ELECTROLYTES, AND NUTRITION: During this
hospitalization, the patient was maintained on TPN with
sliding-scale insulin to control her blood sugars.
#8. On [**2-21**], discussion with the patient's husband, as
well as her daughter, was undertaken regarding the patient's
code status and the patient's code status was changed to DNR
with no pressor, CPR, or shock.
#9. On [**2-22**], the care of this patient was transferred
to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], who will dictate an addendum this
discharge summary.
DR.[**Last Name (STitle) 2466**],[**First Name3 (LF) 2467**] 12-746
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2117-2-22**] 23:47
T: [**2117-2-22**] 11:43
JOB#: [**Job Number 36764**]
|
[
"348.3",
"482.0",
"428.0",
"557.1",
"V10.11",
"780.39",
"560.89",
"276.2",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.25",
"33.24",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
3711, 10884
|
3248, 3694
|
235, 2153
|
2175, 3222
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,274
| 141,884
|
34668+57941
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-9-15**] Discharge Date: [**2182-9-20**]
Date of Birth: [**2115-12-14**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Right leg weakness
Major Surgical or Invasive Procedure:
[**2182-9-15**]: IVC filter placement
[**2182-9-15**]: I&D left hip
[**2182-9-17**]: Hemovac removal
History of Present Illness:
Mr. [**Known lastname **] is a 66 year old man who had a 15 foot fall and
suffered a right intertroch fracture and a T12 burst fracture.
He underwent an ORIF of his right hip on [**2182-9-6**]. He was
transferred to rehab on [**2182-9-12**] and on [**2182-9-15**] he returned to new
numbness and right leg weakness.
Past Medical History:
HTN
Social History:
Married
Works part time driving a truck
Family History:
NC
Physical Exam:
Gen: A&Ox3
HENNT: PERRL, no head trauma
Neck: no neck pain
Lungs: CTAB
Cor: RRR, nml s1/s1, no m/r/g
abd: soft, nt/nd
RLE:
- diffuse swelling prox thigh to ankle although compartments
were compressible
- no sensation below right knee
- [**6-10**] throughout except right [**2-9**] quad, 0/5 AT/[**Last Name (un) 938**]/FHL/GS
- DP/PT palp bilat
Pertinent Results:
Imaging:
[**9-14**] CT Rt lower ext:
1) S/p orif comminuted right intertrochanteric femur fracture.
Large
surrounding hematoma. Although direct comparison to the [**2182-8-26**]
CT is not
possible due to differences in coverage, the degree of soft
tissue swelling appears more pronounced on todays study, based
on the small area of overlap in the proxmial femur.
2) Lucent lesion in the right iliac bone, as detailed above.
Please correlate with any history of carcinoma in this patient.
In absence of known primary malignancy, recommend three month
followup CT scan to confirm stability.
[**9-14**] LENIs:
1. Nonocclusive partial thrombus in the right common femoral,
superficial
femoral, and popliteal veins. Lack of right CFV phasicity and
suboptimal
dampening in response to Valsalva suggesting a possible
downstream thrombus (pelvic veins).
2. Completely occlusive thrombus involving the left posterior
tibial vein.
Partially occlusive thrombus involving the right posterior
tibial vein.
[**9-14**] MRI T-L spine:
1. No significant interval change in the appearance of the
subacute T12
vertebral compression with stable retropulsion of its left
superior cortex and resultant canal narrowing. The focal T2
signal abnormality involving the left lateral aspect of the
spinal cord at this level appears to have resolved in the
interval. There is an old anterior wedge deformity of the T5
vertebral body, but no acute compression is seen.
2. Multilevel disc herniations in the thoracic spine, including
the T7-8
through T9-10 and T5-6 levels. At T9-10, a large central/right
paracentral
and foraminal extrusion significantly indents the spinal cord;
however, the posterior CSF space is maintained and there is no
abnormality of cord
intrinsic signal. The overall appearance is also unchanged.
[**9-14**] RUQ U/S:
There is cholelithiasis without gallbladder
wall thickening or pericholecystic fluid to suggest
cholecystitis. The liver echotexture is unremarkable without
evidence of intra- or extra- hepatic biliary dilatation. The CBD
measures 4 mm. The right and left kidneys are grossly
unremarkable without evidence of hydronephrosis. The main portal
vein demonstrates normal hepatopetal flow. A small pleural
effusion is noted.
Labs:
[**2182-9-14**] 06:10PM BLOOD WBC-12.8*# RBC-2.27* Hgb-6.7* Hct-19.5*
MCV-86 MCH-29.4 MCHC-34.3 RDW-14.2 Plt Ct-387#
[**2182-9-14**] 06:10PM BLOOD PT-36.3* PTT-36.5* INR(PT)-3.9*
[**2182-9-14**] 06:10PM BLOOD Glucose-149* UreaN-41* Creat-1.0 Na-137
K-4.3 Cl-99 HCO3-29 AnGap-13
[**2182-9-15**] 07:32PM BLOOD CK(CPK)-[**Numeric Identifier 16521**]*
[**2182-9-16**] 03:16AM BLOOD Hapto-164
[**2182-9-14**] 06:10PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2182-9-19**] 06:00AM BLOOD WBC-8.2 RBC-3.33* Hgb-9.5* Hct-28.5*
MCV-86 MCH-28.5 MCHC-33.2 RDW-14.1 Plt Ct-396
[**2182-9-20**] 05:50AM BLOOD Hct-28.5*
[**2182-9-19**] 06:00AM BLOOD PT-15.1* PTT-31.0 INR(PT)-1.3*
[**2182-9-20**] 05:50AM BLOOD Glucose-106* UreaN-29* Creat-0.8 Na-139
K-4.3 Cl-103 HCO3-28 AnGap-12
[**2182-9-16**] 03:16AM BLOOD ALT-141* AST-352* LD(LDH)-539*
CK(CPK)-[**Numeric Identifier 79509**]* AlkPhos-172* TotBili-2.8* DirBili-1.8*
IndBili-1.0
[**2182-9-20**] 05:50AM BLOOD ALT-121* AST-83* CK(CPK)-2189*
AlkPhos-432* TotBili-2.8*
Brief Hospital Course:
Mr. [**Known lastname **] presented to the [**Hospital1 18**] on [**2182-9-15**] from rehab with
increased weakness and numbness to his right leg. He was
evaluated by the orthopaedic department and found to have a
thigh hematoma and sciatic nerve palsy. Also his popliteal DVT
was noted to have extension to the femoral vein and a new DVT in
the posterior tibial vein. He was admitted, consented, and
prepped for surgery for hematoma evacuation.
1. Right thigh hematoma:
He received 2units of packed red blood cells and 5 units of FFP
due to supra therapeutic INT. Later that day he underwent an
IVC filter placement and an I&D of his left hip wound. He
tolerated the procedure well, was extubated, transferred to the
recovery room and then to the ICU for serial hematocrits. He
received 2 units of packed red blood cells due to acute blood
loss anemia. On [**2182-9-16**] he was transferred out of the ICU. On
the floor he was seen by physical and occupational therapy to
improve his strength and mobility. He was again transfused with
2 units of packed red blood cells due to acute blood loss
anemia. On [**2182-9-17**] his hemovac was removed. His thigh
compartment was compressible, and his incision was without
significant drainage or erythema during the rest of his stay.
At the time of discharge, his RLE strength was 0/5 in
AT/[**Last Name (un) 938**]/FHL/GS. He had sensation in his RLE down to his ankle
and proximal medial foot. He has no sensation in his right
dorsal foot, most of his plantar foot, and in his toes. He
otherwise had full stength and sensation.
2. DVTs:
He received an IVC filter per above. A hematology consult was
obtained, who agreed with our decision to hold further
anticoagulation within the perioperative period. They also
agreed with our decision to consider restarting coumadin slowly
after his 1 week f/u visit with Dr. [**Last Name (STitle) **]. His INR on
discharge was 1.3.
3. Transaminitis with hyperbilirubinemia:
His LFT's and CK's were noted to be elevated c/w mild
rhabdomyolisis. A medicine consult was obtained, who agreed
with our diagnosis and plan. A RUQ scan was obtained to r/u
cholangitis in the setting of low grade fevers. This was
negative for cholangitis, CBD dilation. Incidentally he was
found to have asxn cholelithiasis. We did hold his simvastatin.
His CKs and LFTs trended down as expected during the rest of
his hospital stay, although his alk phos and total bilirubin
continued to be significantly elevated on discharge. He will
need close f/u by his PCP to trend LFTs. He should have his
LFTs drawn 5 days after discharge (at rehab if necessary).
3. Low grade fevers:
He had intermittent low grade fevers likely from his bilat DVTs.
His CXR was negative for PNA. His urine and blood cultures had
no growth.
4. T12 compression fracture:
An CT and MRI of his T-L spine showed no significant changes in
his subacute T12 compression fractures. There was no epidural
hematoma.
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:
lisinopril 40'; doxazosin 8'; toprol 50'; ASA 160'; ;
simvastatin 40mg'; coumadin (DVT).
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: take while on
oxycodone.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: take while on oxycodone.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation: take while on oxycodone.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right hip fracture
T12 burst fracture
Right foot drop/sciatic nerve palsy
Right thigh hematoma
Acute blood loss anemia
Cholelithiasis
Rhabdomyolysis with transaminitis and hyperbilirubinemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be weight bearing as tolerated on your right leg.
Please wear your TLSO brace at all times when sitting or
standing. Must be put on while laying down.
No anticoagulation until follow up with Dr. [**Last Name (STitle) **] in 1 week.
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, pleaes call the
office or come to the emergency department.
Physical Therapy:
Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Thoracic lumbar spine: when OOB
Treatments Frequency:
Staples/sutures out 14 days after surgery
Dry sterile dressing daily or as needed for drainage or comfort.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics on
[**9-26**], please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Please follow up with Dr. [**Last Name (STitle) 363**] (spine) on [**9-26**], please call
[**Telephone/Fax (1) 3573**] to schedule that appointment.
**[**Doctor Last Name **] and [**Doctor Last Name 363**] both have clinics on Thursday, you can
make appointments for the same day.**
Please follow up hematology at the thrombosis clinic to see Dr.
[**Last Name (STitle) 2805**] on [**2182-10-11**] (Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2182-10-11**] 11:00).
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in x weeks to monitor
your liver tests and follow your INR. You will also need to
schedule a CT of your pelvis in 3 months with the help of your
PCP.
Completed by:[**2182-9-20**] Name: [**Known lastname 12789**],[**Known firstname **] Unit No: [**Numeric Identifier 12790**]
Admission Date: [**2182-9-15**] Discharge Date: [**2182-9-20**]
Date of Birth: [**2115-12-14**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3564**]
Addendum:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**2-6**] weeks to monitor
your liver tests and follow your INR. You will also need to
schedule a CT of your pelvis in 3 months with the help of your
PCP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3565**] MD [**MD Number(2) 3566**]
Completed by:[**2182-9-20**]
|
[
"728.89",
"V54.13",
"997.2",
"728.88",
"V58.61",
"453.41",
"998.12",
"E878.8",
"285.1",
"V54.17",
"E934.2",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"99.05",
"38.7",
"83.02"
] |
icd9pcs
|
[
[
[]
]
] |
11567, 11819
|
4591, 7742
|
339, 445
|
9102, 9111
|
1277, 4568
|
9879, 11544
|
893, 897
|
7881, 8747
|
8888, 9081
|
7768, 7858
|
9135, 9550
|
912, 1258
|
9568, 9725
|
9747, 9856
|
281, 301
|
473, 791
|
813, 819
|
835, 877
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,193
| 112,221
|
34023
|
Discharge summary
|
report
|
Admission Date: [**2186-1-25**] Discharge Date: [**2186-2-6**]
Date of Birth: [**2142-4-6**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Ampicillin / Levofloxacin
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
RLE: significant worsening of pain and swelling
Major Surgical or Invasive Procedure:
[**2186-1-26**] Extensive debridement of right lower extremity.
[**2186-1-27**] Exploration, washout and debridement of right lower
extremity.
History of Present Illness:
This 43-year-old male patient with a history of ESLD, cirrhosis
secondary to hepatitis C, genotype I, He had been followed in
the [**Hospital 1326**] clinic (last visit [**2185-9-21**]). Presented with
mildly encephalopathic status and has significantly worsened
synthetic function of his liver with low albumin, high INR, and
low glucose, MELD 38. Acute on chronic renal failure with uremia
in setting of GNR bacteremia. Pt has significant h/o unilateral
RLE lymphedema, with progressively worsening pain and tenderness
and uncompromised perfusion.
Past Medical History:
PMH:
-Hep C, genotype 1
-Cirrhosis.
-MELD 38
-Hx IVDU
-Chronic unilateral right leg lymphedema
-Chronic renal failure
Social History:
lives with girlfriend and 3 cats at home
+ tobacco - [**12-10**] ppd
denies etoh
+ IVDU - He has a history of IV drug use with heroin and
cocaine between [**2164**] and [**2174**] but denies any use since then.
He repairs computers part time.
He was incarcerated between [**2173**] to [**2177**] for possession of drugs
with intent, and he does smoke an occasional marijuana, but he
reports it is prescribed by doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
Family History:
Non-contributory
Physical Exam:
VS: 98.2 92/34 106 18 92%RA
General: awake orientated, inappropriate responses, anxious.
HEENT: Sclera anicteric, dry MM.
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, mildly hypogastric tender , non-distended, BS+ no
rebound tenderness or guarding, no fluid shift,no visceromegaly,
no herniation.
Ext: Significant RLE 2+, non pitting,very tender tense
compartments, with cellulitis, no crepitus. Pain on passive
flexion/extension. Uncompromised perfusion, pulses preserved. R
inguinal region lymphovarux palpable.
L with mild baseline Lymphedema.
Neuro: A&O x 3, no focal or global deficits.
Pertinent Results:
wbc- 3.6, hct 32.1, plt 16.9, plt 19
diff- n- 82, l- 5.7, e-6
Na 135, Cl 96, K 5.6, CO2 24, BUN 47, Cr 3.9, Glucose 59, Ca
8.2,
Pr 5.4, Albumin 2.3, T bili 4.2, d bili 2.4, AST 131, Alk Phs
57,
ALT 61, CK 115, Mag 1.8
ESR 34
Ammonia 55
INR 2.97 PT 30.5 PTT 47.4
UA- 1.030, ph 5, neg for pro, glu, ketones, RBC [**5-18**], WBC 0-2,
granular casts 0-1, hyaline cast [**1-13**]
Brief Hospital Course:
Patient was admitted with worsening liver disease, acute on
chronic renal failure, with encephalopathy/ uremia in the
setting of GNR bacteremia/sepsis and worsening swelling/
cellulitis of the RLE. He was admitted to the SICU on [**2186-1-25**].
Comparment syndrome was ruled-out, but he was noted to have
increasing erythema, pain and tenderness over the right lower
extremity up into the thigh. He became hypotensive requiring
volume resuscitation and intermittent vasopressors.
Broad-spectrum antibiotics were started. Plans were made to
explore the right lower extremity for concern for a deep
infection and underwent an extensive debridement of the RLE on
[**2186-1-26**]. The patient tolerated the procedure well. He
intermittently required Neo-Synephrine for hypotension in the
OR. He was transferred back to the ICU. On [**2186-1-27**], he was taken
to the OR again for re-exploration of the RLE and to assess the
need for further debridement. A washout and further debridement,
specially of the anterior incision of the lower leg was made. He
was taken intubated on low-dose Neo- Synephrine to the SICU in
guarded condition. He was kept intubated, on neo and on CVVHD
for his renal failure 2ry to ATN. He was initially treated with
Vanc, Cefe, Clinda, flagyl for his GNR on OSH. These actually
grew Pasturella, and additionally, his tissue cx grew staph
coagulase negative (thought to be likely contaminant). He was
continued on Vanco, and started on high dose Cipro, Meropenem
and Clinda, following ID recs. From a nutritional standpoint he
was started on tube feeds on [**1-27**] via dobhoff catheter. The
surgical wounds were managed initially with wet to dry dressing
changes but ultimately with VAC dressings applied at the bedside
and changed every 3 days. The T.Bili progressively increased
from 5.7 preop to 24.6 on [**2-2**]. His transaminases then started
to worsen dramatically to [**Telephone/Fax (1) 78539**] (ALT/AST) on [**2-5**] and up to
3640/[**Numeric Identifier 78540**] on [**2-6**]. His renal function also started to get worse
on [**2-5**] with serum creatinine higher than 2.0 and up to 3.4 on
[**2-6**]. He was evidently coagulopathic due to his liver failure and
his INR was notably high during his stay in the ICU, but
significantly raisen from 2.1 to 3.6 on [**2-4**] and 7.6 on [**2-5**].
His platelets were also notably low, between 20,000-40,000 and
getting down to 12,000 on [**2-2**]. On [**2-3**] his clinical status
changed, started again with hypotension requiring pressors, not
following commands. Additionally, HIT antibody was found to be
positive, thus heparin products were d/c'd and argatroban gtt
was started on [**2-4**]. On [**2-5**] patient was complicated with melena
- ?GI bleed. Argatroban gtt was held and pRBC/FFP/plt were
transfused. NGT lavage was negative. CT head was negative.
Patient had progressive deterioration with significant worsening
LFTs, liver failure, coagulopathy and renal failure. A duplex
U/S of the liver ruled out PVT or HVT. Due to his multiorgan
failure and his progressive clinical deterioration despite
maximal treatment, poor prognosis was discussed with the family
on [**2-6**] and patient was made CMO. Patient expired on [**2186-2-6**] at
7:10 pm.
Medications on Admission:
Dilaudid 15mg PO PRN, Methadone 64 mg liquid qday, Advil PRN,
Lasix 120", aldactone 100', Rifaximin 200mg Q48hours,
Testosterone gel unsure dose
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis by Pasteurella Multocida
Multiorgan failure
Liver Failure, Encephalopathy, Renal Failure, Coagulopathy
HCV cirrhosis
RLE cellulits s/p I&D and debridement [**1-26**] and [**1-27**]
Heparin Induced Thrombocytopenia
Cardiopulmonary Arrest
Discharge Condition:
Expired
Completed by:[**2186-2-24**]
|
[
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"995.92",
"403.91",
"289.84",
"728.89",
"027.2",
"305.63",
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"V58.69",
"305.53",
"682.6",
"518.81",
"571.5",
"785.52",
"070.71",
"799.02",
"276.2",
"038.8",
"E905.1",
"285.29",
"584.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"83.39",
"96.72",
"38.91",
"38.95",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6349, 6358
|
2885, 6125
|
354, 498
|
6645, 6683
|
2485, 2862
|
1734, 1752
|
6320, 6326
|
6379, 6624
|
6151, 6297
|
1767, 2466
|
267, 316
|
526, 1078
|
1100, 1220
|
1236, 1718
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,433
| 174,646
|
47713
|
Discharge summary
|
report
|
Admission Date: [**2138-11-14**] Discharge Date: [**2138-11-20**]
Date of Birth: [**2054-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
PCP: [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**], MD
.
CHIEF COMPLAINT: s/p mechanical fall
REASON FOR MICU ADMISSION: GI bleed
Major Surgical or Invasive Procedure:
EGD and colonoscopy on [**2138-11-17**]
History of Present Illness:
Ms. [**Known lastname **] is an 84 y.o. F with h/o falls, atrial
fibrillation on coumadin, chronic kidney disease stage IV, HTN,
and T2 DM, who presents s/p mechanical fall day prior to
admission. Pt fell down 1 step and slid down to her knees as she
was holding on to the door. Denied neck and back pain. Denies
loss of consciousness. She was ambulatory after the fall and
drove herself home, but the pain increased this AM in her left
knee. She complained of bilateral knee pain, L > R, and thus,
presented to the ED. She has noted darker colored stools for the
last 1-2 months, but denies BRBPR, hemorrhoids. Has 1 BM per
day. Denies lightheadedness, dizziness. Last colonoscopy > 10
years ago and reportedly negative.
.
In the ED, initial VS: T 97.5 HR 109 BP 162/62 RR 16 O2 100%RA.
VS in ED: 134-162/44-60, HR 88-109. Labs drawn, significant for
Hct 22 and INR 4.3. Knee X-rays and EKG performed. Rectal
performed by GI showed reddish tinged, dark brown, guiaic
positive. NG lavage negative. GI consulted. Pt given
oxycodone-acetaminophen 5/325 po x 1, pantoprazole 40 mg IV x 1,
Vitamin K 10 mg IV x 1, 2 L NS. Active T&S. Ordered for 2pRBC,
not hung. 2 large bore PIVs placed. Physical Therapy consulted
in ED and recommended home with PT.
.
Currently, she has L > R knee pain, [**6-22**], aching.
.
ROS: Denies fever, chills, cough, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria. + dark stools
Past Medical History:
- Type 2 Diabetes Mellitus
- Atrial Fibrillation on Coumadin
- Hypertension
- Hyperlipidemia
- Pulmonary arterial hypertension
- Chronic kidney disease
- Anemia
- Hyperparathyroidism s/p parathyroidectomy [**6-21**]
- Pelvic fracture lateral compression type I and a left proximal
humerus fracture [**10-21**]
- s/p Hysterectomy
Social History:
She never smoked. Last drink [**2-14**] glass of wine 1 week ago. Lives
with sister, walks on her own.
Family History:
Her mother had hypertension, died at 89. Her father had lung
cancer, died at 74. Denies colon cancer, colon polyps in family.
Physical Exam:
Vitals - T: 96.6 BP: 151/41 HR: 102 RR: [**9-28**] 02 sat: 96% RA
GENERAL: pleaseant, elderly female in NAD
HEENT: EOMI, anicteric, conjunctivae pink, MMM, no cervical LAD
CARDIAC: irreg irreg, no m/r/g
LUNG: CTAB, no w/r/r
ABDOMEN: NDNT, soft, 2 ecchymoses 3x3 cm on R mid abdomen and L
mid abdomen, NABS
EXT: no c/c/e, 2+ DP, L knee with inner ecchymoses and
ballotable swelling, R knees with ballotable swelling
NEURO: A&O x 3
DERM: no rashes
Pertinent Results:
Labs on admission:
LABS:
WBC 9.6
h/h 8.6/25 --> s/p 2U PRBC's
plts 228
INR currently 1.5 <-- 4.3 on presentation
Chems significant for glucose 53, BUN/Cr 106/3.6
.
B12 normal
.
Iron 58 (30-160)
TIBC 242 (260-470)
Ferritin 430 (13-150)
Transferrin 186 (200-360)
.
UA with negative blood, negative nitrites Lg LE, 168 WBC's, mod
bacteria, however was asymptomatic
.
By discharge
Hct had stabilized in the high 24's.
WBC 5.8
Plts 179
INR had decreased to 1.2
BUN/Cr was within baseline 63/2.8
Digoxin level normal 0.8
MICROBIOLOGY: None.
BILATERAL KNEE XRAYS (WET READ): No acute fracture or
dislocation. Unchanged calcinosis in bilateral compartment.
Subchondral cyst in superior pole of patella. Vascular
calcifications again noted. No large joint effusions.
.
[**2138-11-17**] GI Bx's
Colonic polypectomies:
A. Hepatic flexure:
Adenoma.
B. Transverse, polyp:
Sessile serrated adenoma.
Brief Hospital Course:
84 y.o. F with h/o falls, atrial fibrillation on coumadin,
chronic kidney disease, HTN, and T2 DM, who presents s/p
mechanical fall day prior to admission, incidentally found to
have worsening anemia with guiaic + stools in setting of
supratherapeutic INR.
1. GIB: Given negative NG lavage, guiaic positive reddish brown
stools on rectal, likely lower GI bleed; however, may also be
oozing from upper GI tract given supratherapeutic INR of 4.3.
Hemodynamically stable in ED. Pt received vitamin K IV 10 mg x 1
in ED. Patient received a total of 3U PRBC's. Hct remained
stable for >48 hours in the high 24's by the time of discharge.
No gross bleeding was seen after admission, no worrisome changes
in vitals signs. On [**2138-11-17**] the pt went for EGD/colonoscopy
which showed diverticuloses in colon and two polyps which were
removed with pathology as above. The prep was considered limited
and GI recommended a repeat colonoscopy for further evaluation
as well as a capsule endoscopy to evaluate the small bowel in
the near future. These procedures were deferred to the outpt
setting, and will need to be followed up on by the pt's PCP.
2. S/p mechanical fall--Pt had plain films showing no fracture.
She did have large effusions on the medial aspect of her
chronically arthritic knees. Pain was only an occasional
complaint during admission and was relieved with small amts of
narcotics, lidocaine patches, and Tylenol. Physical therapy came
to work with her both while she was in the unit, at which time
they cleared her for home with PT services, and also while she
on the floor, at which time they recommended the same. The pt
was seen to be ambulating the halls with a walker and able to
climb stairs without difficulty.
3. HTN--All HTN meds were held on admission. Subsequently
Propanolol and Valsartan were added back. However, other bp meds
Lasix, Hydralazine, and Nifedipine continued to be held and this
will need to be addressed by PCP. [**Name10 (NameIs) **] was ranging between
120-150 on the day of discharge.
4. Type 2 DM: Pt was seen to have 2 episodes of symptomatic
hypoglycemia which resolved with juice and crackers. Her insulin
regimen was made less aggressive on admission to the floor with
an regimen of NPH [**12-2**] in the am/pm and sliding scale insulin
as well. She felt that she was not eating as much as she does at
home. After this change she did not have any more episodes of
hypoglycemia. On discharge, we lowered her home regimen of
Humalog 75/25 from its original dose of 25/40 in the am/pm to a
lower dose of 15/30 in the am/pm. She stated she checks her
finger sticks often and would continue to do so until follow up.
This is another aspect of her care that will need to be followed
in the outpt setting.
5. [**Name (NI) 100757**] pt was maintained on Digoxin. A level was measured
at 0.8. Rate was also controlled with Propanolol which was added
back when her Hct was stable and it was clear she was not
bleeding. The patient had excellent heart rate control and no
episodes of RVR while admitted.
The pt's Coumadin was also held in the setting of active
bleeding, and was not restarted while admitted. Her INR was 4.3
on admission and 1.2 by discharge. This is another issue that
will need to be addressed by pt's PCP. [**Name10 (NameIs) **] has a high risk for
stroke according to CHADS2 and will likely need to be restarted,
however as was discussed, she also has a h/o falls. Therefore
risks/benefits will need to be weighed when restarting
anticoagulation. Currently the risks of a recurrent GIB and fall
appear to outweight the risk of stroke. This was discussed with
the patient and the patient agreed with the management.
6. [**Name (NI) 94062**] pt was seen to be chronically anemic, with a
picture consistent with anemia of chronic disease and was given
a dose of erythropoietin on the advice of her nephrologist. She
was NOT given a prescription for this on discharge and this will
need to be followed up, likely by her nephrologist or PCP.
7. Acute on Chronic Renal [**Name (NI) 94059**] pt's Cr on transfer from
the ICU was within limits of her baseline and by discharge was
also within limits of baseline. This was not an acute issue
while on the floor.
8. Hyperlipidemia--Continued home atorvastatin.
9. Hyperparathyroidism--Followed by Dr. [**Last Name (STitle) 13059**] at [**Hospital1 18**].
Continued Calcium and Vitamin D supplementation
# CODE: DNR/DNI (confirmed with patient)
IN CONCLUSION: For the outpt provider, [**Name10 (NameIs) **] are several
considerations after discharge.
1. We stopped her Coumadin in the setting of bleed, she has high
CHADS2 and will likely need to be restarted soon, but with the
understanding that she has now had at least 2 falls.
2. She had a GI bleed and her Hct was stable on d/c, please
check a Hct and make sure it is steady.
3. We have her back on 3 of her 5 home HTN meds (Valsartan and
Propanolol) but Lasix, Nifedipine, and Hydralazine were not
added back, please check her bp.
4. We changed her original insulin regimen as above to a less
aggressive regimen. Please follow up her finger sticks and
adjust accordingly.
5. She received Epogen while in house, may want to consider
continuing
Medications on Admission:
Atorvastatin 20 mg po daily
Digoxin 125 mcg po daily
Folic acid 1 mg po daily
Lasix 60 mg po daily
Hydralazine 67.5 mg po BID
Hydralazine 50 mg po qhs
Humalog 75-25 - 25 units q AM, 40 units q PM
Nifedipine ER 60 mg po daily
Propanolol SR 80 mg po daily
Valsartan 320 mg po daily
Coumadin 2.5 mg po daily or directed by [**Hospital **] Clinic
Calcium carbonate 1000 mg po QID
Tylenol OTC
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension
Sig: One (1) injection Subcutaneous twice a day: Take 15U every
morning and 30U every evening.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*5*
7. Propranolol 80 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
8. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) dose
Injection QMOWEFR (Monday -Wednesday-Friday).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
CareGroup
Discharge Diagnosis:
Anemia due to acute blood loss, likely from GI tract
Trauma to knees due to mechanical fall without loss of
consciousness
AFib
Hypertension
Chronic Renal Insufficiency
Diabetes type 2
Hyperlipidemia
Discharge Condition:
By the time of discharge, the pt's Hct was stable, was not
losing blood from any source, vital signs were stable, pt was
taking good PO food and liquids, was ambulating with a walker,
and was medically clear for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after a fall in which you injured
your knees. During your evaluation you were noted to have a drop
in your blood level and were also noted to have blood coming
from your GI tract. You were admitted to the intensive care unit
and given some blood products. After you stabilized, you
underwent a procedure to visualize your GI tract. The bowel prep
was poor and your GI tract was not properly visualized, however
your colon was seen to have diverticuli and also several polyps
were removed. The GI doctors [**Name5 (PTitle) 2985**] a repeat colonoscopy with a
better prep was warranted in the future.
CHANGES TO YOUR MEDICATIONS:
1. While you were admitted, your anticoagulation medicine
Coumadin was held because it can aggravate bleeding problems.
2. [**Name2 (NI) **] of your blood pressure meds were also held due to
concern of low blood pressures. You were kept on Digoxin,
Propanolol, and Valsartan, but Lasix, Hydralazine, and
Nifedipine were all held. You will need to follow up with your
primary care physician (PCP) to asssess your blood pressure and
whether you need to restart these meds.
3. Your insulin regimen was also made less aggressive as it was
seen that your blood sugars were occasionally too low. After
discharge, you should temporarily lower your insulin regimen to
Humalog Mix 75/25 --> 15 units in the morning and 30 units in
the evening. You should continue to monitor your blood sugars
and follow up with your PCP to evaluate your sugars--they may
need to be increased or decreased accordingly.
4. You were started on Erythropoietin shots, which will help
your bone marrow make more blood.
5. You were started on Vitamin D which contributes to bone
health
6. You were started on oral Pantoprazole which makes your
stomach less acidic
Please return to the hospital if you experience any fevers,
chills, night sweats, continued blood loss from your GI system,
or any blood loss anywhere, abdominal pain that does not
resolve, shortness of breath, chest pain, dizziness, new pain in
your knees or pain that is not resolved with medications, or any
other concerns.
Followup Instructions:
Please follow up with:
1. [**Company 191**] discharge clinic, [**Hospital Ward Name 23**] Building, [**Location (un) **] in [**Hospital Ward Name 5074**], [**Hospital1 18**]
Tuesday [**11-25**], 2:50pm
Have your hematocrit checked --> This is VERY IMPORTANT. Make
sure your healthcare provider knows what your hematocrit level
is. During this appointment please have them schedule you an
appointment with your PCP [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**] who is also at [**Hospital **].
2. Dr. [**First Name8 (NamePattern2) 437**] [**Last Name (NamePattern1) 20540**]
GI fellow who performed your colonoscopy
Wednesday [**11-26**], at 3pm.
[**Location (un) 453**] [**Hospital Unit Name **] on [**Initials (NamePattern4) 1388**] [**Last Name (NamePattern4) **]
4. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Name8 (MD) 20868**], NP in Nephrology
[**12-5**], at 10am
[**Last Name (un) **] Diabetes Center
Completed by:[**2138-11-20**]
|
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"285.1",
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"V58.67",
"790.92",
"578.9",
"E934.2",
"403.90",
"416.8",
"585.4",
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.42",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10770, 10810
|
4065, 9278
|
477, 519
|
11053, 11278
|
3146, 3151
|
13455, 14456
|
2535, 2663
|
9717, 10747
|
10831, 11032
|
9304, 9694
|
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|
2678, 3127
|
11971, 13432
|
381, 439
|
547, 2045
|
3165, 4042
|
2067, 2399
|
2415, 2519
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,360
| 131,538
|
50929
|
Discharge summary
|
report
|
Admission Date: [**2151-6-26**] Discharge Date: [**2151-6-30**]
Date of Birth: [**2088-12-23**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Levaquin
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Fevers and nausea and vomiting
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
62 yo F DNR/DNI w/PMHx sx for alcoholic cirrhosis and breast
cancer who presented to the ED with nausea, vomiting, diarrhea
and malaise as well as continued shoulder pain from prior fall.
She was given a prescription for a UTI recently, but did not
fill this. Patient was febrile to 102 in the ED, and was
hypertensive and tachycardic concerning for alcohol withdrawal,
and was given Valium 40 mg IV in the ED. Patient was admitted to
the [**Hospital Unit Name 153**] for alcohol withdrawal and was found to have bacteremia
(2/2 bottles GNR) and was started on vancomycin and ceftriaxone,
with a positive UA.
Past Medical History:
# HTN - per OMR
#[**Medical Record Number **]Recent pansens Ecoli UTI
# Long [**Medical Record Number 5937**] from compazine/cipro combo
# Cirrhosis EtOH and HCV
# Hypokalemia
# h/o rheumatic fever
# h/o acute hepatitis A after trip to [**Country 3399**] in [**2117**]
# h/o salmonella - while in [**Country **] in [**2138**]
# depression - was on prozac and nortriptyline in past
# multiple BCC and AK, s/p cryosurgery
# s/p excision of R breast nodule [**2142-5-8**]: atypical ductal
hyperplasia
# migraines
# childhood illnesses - Measles, mumps, chickenpox.
# EtOH abuse - active currently
Social History:
Pt lives alone. Never married, no children. Retired editor. Most
of her family is deceased, with the exception of a sister who
lives in [**State 5887**]. She has not spoken to her sister in 5
years. Former heavy EtOH (until [**2143**]) and continues to use
alcohol. No tobacco
Family History:
Lung cancer, rectal cancer.
Physical Exam:
VS: 102.8 HR 146 -> 100, 128/75 28 98% 5L
GEN: asleep but arousable. slightly tremulous, ill appearing.
NEURO: aao to person, [**Location (un) **], day, month, but not year.
Displays repetition and perseveration in questioning.
- CN: PERRLA, EOMI, face symmetric, face [**Last Name (un) 36**] intact, tongue
midline, shoulder nl. Toes down bilat, upper strength intact
bilat.
- pos tremor bilat. neg asterixis
- feels "anxious" and displays agitation intermittently.
HEENT: anicteric, MM dry. JVP flat.
CARDS: tachy, reg
RESP: clear bilat without consolidation or effusion
GI: BS+ NT ND soft, no masses, no guarding, no HSM
RECTAL: OB neg, brown stool
EXT: no edema. has right shoulder tenderness on passive and
active abduction
Pertinent Results:
Lactate 2.1 -> 1.8
141 98 10
---------------< 160
3.2 29 0.7
mag 1.1
.
WBC: 6.4
HCT: 34.9
PLT: 181
N:76.7 L:20.4 M:2.2 E:0.3 Bas:0.4
.
CXR: PA and lateral chest compared to [**6-26**]:
Linear opacification in the right lower lung is probably
subsegmental
atelectasis, more extensive irregular opacification in the left
mid lung is
new since [**6-26**] and could represent bronchopneumonia. The
region of more
dense consolidation in the infrahilar left lower lobe has
cleared and
depression of the left hilus has resolved indicating that this
was
atelectasis. Heart size is normal. There is no pleural effusion.
The study and the report were reviewed by the staff radiologist.
.
UA positive
.
EKG: NSR, NA [**Month (only) 5937**] 450. TWI III, aVF c/w prior
.
Blood cultures positive for pansensitive E. coli. Urine culture
growing gram negative rods.
Brief Hospital Course:
For patient's sepsis, she grew 2 bottles of gram negative rods,
one of which speciated to E. coli, which was pansensitive. She
had associated leukocytosis, fever, and tachycardia, consistent
with sepsis. Her UA was positive, and eventually urine culture
grew gram negative rods as well. She was treated initially with
vancomycin and ceftriaxone. This was narrowed to ceftriaxone
alone for which she needs a [**10-5**] day course. A PICC was placed
for antibiotics to be completed at her rehab. Serial blood
cultures were negative. A renal ultrasound was performed to
evaluate for perinephric abscess and this was negative.
She was noted to have an infiltrate on CXR consistent with a
community acquired pneumonia. She was placed on azithromycin as
well for a total five day course to be completed at rehab.
Patient also had a headache, which improved with motrin and
tylenol. She complained of ear pain. Her HEENT and neurological
exam was unremarkable. Her headache was felt to be secondary to
neck spasms, and she was given warm packs. Physical therapy
evaluated her and felt that she should have physical therapy as
an outpatient.
Patient was felt to be in acute alcohol withdrawal as well. She
was given valium, and then switched to lorazepam given her
history of liver diseases. She was given a MVI/thiamine/folate,
and was evaluated by social work. Her CIWA was discontinued one
day before discharge.
She was pancytopenic, thought to be from marrow suppression from
alcohol use. She did not require any blood transfusions.
For her alcoholic cirrhosis, she was not encephalopathic during
her admission. She was given lactulose. Her breast cancer was
stable, and will need to be followed up as an outpatient.
Her code status was made DNR/DNI.
Medications on Admission:
ASA 325
Folic acid daily
thiamine 100 daily
MVI
B12 daily
Potassium daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
10. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gm Intravenous Q24H (every 24 hours) for 8 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. E. coli sepsis
2. Pyelonephritis
3. Pancytopenia
4. Tension headache
5. Alcohol withdrawal
6. Alcohol use
7. Community acquired pneumonia
Discharge Condition:
Improved from admission.
Discharge Instructions:
You were admitted with sepsis from a urine infection as well as
a pneumonia. You were treated with IV antibiotics.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2204**] 7-10 days after discharge
from your skilled nursing facility. The number to call to make
the appointment is [**Telephone/Fax (1) 2205**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2151-9-24**] 1:00
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2151-9-28**] 1:15
|
[
"571.2",
"174.8",
"401.9",
"486",
"038.42",
"291.81",
"284.1",
"590.10",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6331, 6401
|
3588, 5342
|
320, 341
|
6586, 6613
|
2705, 3565
|
6776, 7283
|
1909, 1938
|
5466, 6308
|
6422, 6565
|
5368, 5443
|
6637, 6753
|
1953, 2686
|
250, 282
|
369, 979
|
1001, 1597
|
1613, 1893
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,362
| 119,584
|
8887
|
Discharge summary
|
report
|
Admission Date: [**2132-9-28**] Discharge Date: [**2132-10-1**]
Date of Birth: [**2059-10-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
abdominal distension and constipation
Major Surgical or Invasive Procedure:
Paracentesis on [**2132-9-29**]
History of Present Illness:
72 year old Chinese-speaking male with widely metastatic gastric
adenocarcinoma involving pancreas and surrounding vasculature
sent in by VNA for distended abdomen and no bowel movement. He
was recently admitted to surgical service from [**Date range (1) 30925**] for
dehydration, N/V. He was not felt to be a surgical candidate.
He was tolerating small amounts of po's. Per patient his last
bowel movement was [**9-25**] (day of discharge). He has been taking
small amounts of po's at home and has been having some abd pain
in epigastrium after eating. He also notes at night bilateral
abdominal discomfort but better now since fentanyl patch was
added. He is not clear which medications he is taking, although
brings bag of meds (see below)
.
ROS: no fevers, chills, no current abdominal pain, nausea or
vomiting. No chest pain, shortness of breath. Mild ankle
swelling bilaterally. No blood in stools.
.
ED: HR 120's-130's. bp stable. NG tube placed. CXR, KUB done.
CT Abd/Pelvis done with ileus and increased ascites. Given
ondansetron x 2. Rectal done and no stool in the vault.
Oncology was notified of admission to [**Hospital Unit Name 153**]. Received 1L NS.
Past Medical History:
metastatic gastric adenocarcinoma: EGD with biopsy of
gastric body on [**2132-9-5**] revealed invasive poorly differentiated
adenocarcinoma with rare signet ring cells. CT findings of a
5.6 x 6.7cm gastric mass extending to the pancreas with
circumferental
narrowing of the cardia. Local encasement of the celiac artery
and common hepatic artery as well as a 1.8cm retroperitoneal
node were present. A 4mm hypodense lesion was seen in the liver.
Two sub-centimeter small pulmonary nodules were seen as well.
Started on xeloda [**2132-9-27**]
.
HTN
hyperlipidemia
CAD s/p cardiac stent
COPD/asthma
history of gastric ulcer and colon polyps (adenoma)
possible h/o TB treated with 3 month "injections"
Social History:
Single, no children. Lives in [**Hospital1 392**]. Remote tobacco (2-3ppd x
2- yrs, quit > 20 yrs ago), no heavy EtOH. Immigrated from [**Location (un) 30926**] in [**2120**].
Family History:
Mother with Pancreatic cancer, Father with Liver cancer;
no gastric or colon cancer
Physical Exam:
V: 95.0F HR 121 164/80 20 94/2L
Gen: awake, alert and oriented, audibly wheezing, tachypneic
HEENT: PERRL, anicteric sclera, OP dry but clear
Neck: supple, no JVD
CV: regular, tachycardic, no murmurs
Pulm: bibasilar crackles, expiratory wheezing throughout
Abd: Hypoactive bowel sounds, tense, distended, nontender to
palpation, unable to assess hepatosplenomegaly
Ext: warm, bilateral lower extremity edema, nontender
skin: no rash
rectal: guaiac neg, no stool in vault
Pertinent Results:
[**2132-9-28**] WBC-13.1* RBC-4.62 Hgb-13.6* Hct-38.3* MCV-83 MCH-29.5
MCHC-35.5* RDW-13.4 Plt Ct-492* Neuts-87.5* Lymphs-6.7*
Monos-4.9 Eos-0.8 Baso-0.1
[**2132-9-30**] WBC-15.6* RBC-4.50* Hgb-13.3* Hct-38.6* MCV-86
MCH-29.5 MCHC-34.4 RDW-13.7 Plt Ct-562*
[**2132-9-28**] 04:10PM BLOOD PT-11.9 PTT-25.6 INR(PT)-1.0
[**2132-9-28**] Glucose-155* UreaN-17 Creat-0.7 Na-128* K-4.5 Cl-90*
HCO3-25
ALT-18 AST-26 AlkPhos-95 Amylase-32 TotBili-0.7
[**2132-9-29**] Glucose-128* UreaN-14 Creat-0.6 Na-130* K-4.5 Cl-93*
HCO3-Calcium-7.9* Phos-3.8 Mg-2.0 Albumin-2.8*
[**2132-9-30**] Glucose-167* UreaN-17 Creat-0.7 Na-132* K-5.0 Cl-97
HCO3-27 Calcium-8.2* Phos-3.2 Mg-2.2
[**2132-9-29**] 03:33AM ASCITES WBC-690* RBC-3635* Polys-25* Lymphs-33*
Monos-9* Mesothe-3* Macroph-30*
[**2132-9-29**] 03:33AM ASCITES TotPro-3.6 Glucose-110 Creat-0.5
LD(LDH)-351 Amylase-17 TotBili-0.6 Albumin-2.1
[**2132-9-29**] 3:33 am PERITONEAL FLUID
GRAM STAIN (Final [**2132-9-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE : negative
ANAEROBIC CULTURE : negativ
FUNGAL CULTURE : NO FUNGUS ISOLATED.
EKG [**2132-9-28**]: sinus tachy HR 120, Nl axis/intervals, flattened T
waves II, III, aVF. No q waves.
[**2132-9-28**] CT Abd/Pelvis: Gastric mass with extension posteriorly
to pancreas as previously noted with diffuse peritoneal
carcinomatosis and worsening of large volume ascities. Abnormal
hepatic perfusion with new mild intrahepatic biliary dilatation.
Reticulonodular pattern at lung bases new and may represent
metastatic disease though infection should be excluded
clinically. Large bilateral hilar lymph nodes bilaterally. New
small pleural effusions.
[**2132-9-28**] CXR: Reticular and nodular opacities in the lower lungs,
right greater than left, which are worrisome for metastatic
disease.
Chronic changes in the right lung apex may be related to prior
TB.
NG tube extending into the left upper quadrant.
[**2132-9-28**] KUB: No evidence of bowel obstruction or ileus. NG tube
in good position.
<b>Discharge Labs:</b>
[**2132-10-1**] 06:40AM BLOOD WBC-14.0* RBC-4.77 Hgb-13.9* Hct-41.2
MCV-86 MCH-29.2 MCHC-33.8 RDW-13.7 Plt Ct-542*
[**2132-10-1**] 06:40AM BLOOD Glucose-125* UreaN-22* Creat-0.7 Na-134
K-5.1 Cl-97 HCO3-30 AnGap-12
[**2132-10-1**] 06:40AM BLOOD ALT-13 AST-16 AlkPhos-90 TotBili-0.5
[**2132-10-1**] 06:40AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3
Brief Hospital Course:
72 year old male with newly diagnosed stage IV gastric
adenocarcinoma, peritoneal carcinomatosis presenting with
increased abdominal distension, ascites and no bowel movement x
3 days.
.
# widely metastatic gastric cancer - patient has been evaluated
by surgery and is not a surgical candidate. He was seen by
Heme-Onc during his last hospitalization and scheduled for outpt
follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for palliative chemo options
(Has not yet seen Dr. [**Last Name (STitle) **]. Seen by Palliative Care
yesterday who spoke with nephew, [**Name (NI) **]. Appreciate
interventions. Are willing to assist in Family Meeting.
Oncology recommended continuing with xeloda as an outpatient and
they will continue to follow. Continue pain management with
fentanyl patch and morphine elixir at home. Hospice service
will follow the patient at home.
# abd distension - Initial concern for ileus on admission,
however, no evidence of ileus on admission. Patient has been
constipated for 2 weeks although had a bowel movement 3 days
prior to admission. He was not taking bowel regimen (colace,
senna, MOM) at home. He had 4 bowel movements on [**2132-9-29**] after
restarting colace, senna and lactulose so this can be held for a
few days. His abdominal distension was from large ascites. He
had a paracentesis with 3.5L amber colored drainage (some blood
so from malignant ascites from peritoneal carcinomatosis).
Patient will be set up with Interventional Radiology
paracentesis after discharge. Will likely need outpatient
paracentesis every 5-7 days. He is not a candidate for port
placement (for home drainage) until he is on hospice (ie - no
longer taking xeloda or other chemotherapy) per Oncology. He is
tolerating po's.
# Tachycardia - Resolved the night of admit with paracentesis of
3.5L, reinstitution of metoprolol and fluid bolus of 1L. Thus,
likely resultant from hypovolemia, increased abdominal pressure
and b-blocker withdrawal. Also considered dehydration, not
taking metoprolol, side-effect from xeloda and PE. No note of
tachycardia on his last discharge, EKG on [**9-23**] w/ HR 95. Heart
rate 70's-90's thereafter.
# Wheezing - has asthma and emphysema. Patient denies feeling
short of breath. Abdominal ascites may have been contributing
to taking rapid breaths and wheezing.
Started nebulizer treatments. Patient set up with home oxygen
prior to discharge as he remained on 2L oxygen after
paracentesis (O2 sat < 88% at rest and with ambulation on room
air). Continued on home inhalers on discharge.
# Hyponatremia - IMPROVED, although seen on last
hospitalization. Volume status consistent with hypovolemia.
Given NS as IV fluid and sodium improved.
# HTN - RESOLVED. Improved night of admit s/p paracentesis and
reinitiation of metoprolol. Continued on home dose of
metoprolol.
After patient was initially in the ICU, he was transferred to
the floor and remained stable.
Medications on Admission:
HOME MEDS:
metoprolol 12.5mg po bid
Fluticasone 110 mcg/Actuation 2 puffs inh [**Hospital1 **]
Metoclopramide 10 mg PO QIDACHS
Fentanyl 25 mcg/hr Patch 72 hr
MEDS on D/C SUMMARY - not taking at home
Pantoprazole 40 mg po daily
Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs inh q6hrs prn
Ativan 0.5 mg po q8hrs prn
Compazine 10 mg po tid
colace/senna/Milk of Magnesia 311 mg po tid prn
Morphine 10 mg/5 mL Solution: [**5-8**] ml PO Q2H hrs prn
Sodium Chloride 1 g Tablet PO DAILY (?)
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
4. Combivent 103-18 mcg/Actuation Aerosol Sig: [**1-1**] Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 INH* Refills:*2*
5. Morphine 10 mg/5 mL Solution Sig: [**5-8**] ml PO q2hrs as needed
for pain.
Disp:*qs mL* Refills:*0*
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS.
Disp:*120 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
8. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal once
a day.
Disp:*10 Patches* Refills:*0*
9. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
10. Milk Of Magnesia Concentrated 2,400 mg/10 mL Suspension Sig:
30ml PO twice a day as needed for constipation.
Disp:*qs 1 month * Refills:*1*
11. Xeloda 500 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Lactulose 10 g/15 mL Solution Sig: 15-30 mL PO twice a day
as needed for constipation.
Disp:*600 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Location (un) 86**] and Greater [**Hospital1 1474**]
Discharge Diagnosis:
Metastatic gastric adenocarcinoma
COPD
Malignant ascites
hypertension
Discharge Condition:
Hemodynamically stable on 2L NC.
Discharge Instructions:
You were admitted with a fast heart rate and ascites (fluid
accumulation in your abdomen). You received a paracentesis to
remove fluid from your abdomen. No infection was found. You
should follow up for the paracenteses and oncology appointments
as scheduled.
You were constipated when you came in, it is important that you
take stool softeners if you feel constipated. We have started
you on colace twice daily and senna to be taken twice daily as
needed to help you have a bowel movement.
We have arranged to have oxygen delivered to your home. It is
important to wear this at home (2L by nasal canula) as your
oxygen levels are low.
.
Please call your doctor or return to the emergency room for:
-Increased Abdominal Pain or swelling
-difficulty breathing
-fever
Followup Instructions:
You were scheduled to have another paracentesis performed on
[**2132-10-3**] at 1:00 PM in the [**Hospital Unit Name 1825**] ([**Hospital Ward Name 516**]), [**Location (un) 3202**]. You also have a paracentesis on [**2132-10-8**] at 1PM in the
same location. Please call ([**Telephone/Fax (1) 6713**] if you have any
questions or to reschedule the appointment.
.
Oncology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2132-10-8**] 4:00. [**Hospital Ward Name 23**] Center, [**Location (un) 24**].
.
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 17362**] [**Name (STitle) **]. [**Telephone/Fax (1) 8236**]. Please call for a follow
up appointment in [**2-2**] weeks.
|
[
"276.1",
"493.20",
"V45.82",
"197.8",
"V12.72",
"197.6",
"272.4",
"151.4",
"V12.71",
"414.01",
"789.51",
"401.9",
"263.9",
"511.9",
"V66.7",
"799.02",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10527, 10624
|
5581, 8558
|
353, 387
|
10738, 10773
|
3134, 5198
|
11594, 12366
|
2536, 2621
|
9096, 10504
|
10645, 10717
|
8584, 9073
|
10797, 11571
|
5213, 5558
|
2636, 3115
|
276, 315
|
415, 1601
|
1623, 2326
|
2342, 2520
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,899
| 118,408
|
35133
|
Discharge summary
|
report
|
Admission Date: [**2120-12-30**] Discharge Date: [**2121-1-3**]
Date of Birth: [**2040-2-23**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Recurrent Intracranial hemorrhage
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
80 year-old woman with a history of a recent right frontal
hemorrhage with left hemiparesis (discharged from [**Hospital1 18**] [**12-6**]), hypertension, dyslipidemia, coronary artery disease s/p
MI
with stent placement, and hypothyroidism, who returns today as a
transfer from an outside hospital for worsening left-sided
weakness.
The patient's nurse spoke at [**Hospital 582**] Rehabilitation spoke with
Neurology attending Dr. [**Last Name (STitle) **] at ~10 am today. According to
her
nurse, on Friday, the patient was able to sit in a chair, feed
herself, say short phrases, and move her left arm and leg "to a
limited extent." Today, the nurse noted the patient had a
notable left-sided flaccid hemiplegia. She was not vocalizing.
The time of onset is unclear from documentation, though she was
noted to be sleeping from 11 pm to 7 am. A note from OT today
states that she was able to follow a three-step command and move
her left-side to command on [**11-27**]. However today, she was
able to follow only a one-step command and was unable to move
her
left side to command.
She was then brought to [**Hospital3 3765**]. There, documentation
notes that her left side was flaccid with a left-upgoing toe.
By
report, a head CT there revealed a new right frontal bleed, more
posterior than her prior. There was mild associated edema but
no
significant mass effect. WBC was 9.5 with neutrophilic
predominance (81%). Chemistry was unremarkable. TSH was
significantly elevated at 20.2. ESR was 41. Urinalysis was
concerning for a urinary tract infection: turbid, large blood
([**10-23**] RBC), 30 protein, large leukocyte esterase, positive
nitrites, many bacteria, and rare calcium oxalate crystals. EKG
was sinus rhythm at a rate of 82. She was loaded with
fosphenytoin and a dose of Rocephin for the presumed urinary
tract infection. Of note, it appears that she was on Levaquin
at
her rehabilitation facility (per OSH note).
Of note, she was admitted to the neurologic-ICU on [**11-19**]
for a large, spontaneous right lobar hemorrhage with edema. (Of
note, she was on a full daily Aspirin and Plavix at the time.)
There was and mass effect on the right lateral ventricle and 4
mm
shift to the left. A small amount of hydrocephalus as well as
subarachnoid and intraventricular hemorrhage was noted. Her
hemorrhage was stable with sequential imaging. Though there was
concern for amyloid angiopathy as the underlying process, an MRI
did not reveal microbleeds. A CTA did not reveal an underlying
vascular malformation. On transfer to the floor, she developed
hyponatremia to ~127 that improved after her hydrochlorothiazide
was discontinued. She also developed a urinary tract infection
with both enterococcus and E. coli which was treated with a week
course of vancomycin and ceftriaxone respectively. She also
developed soft stools, though C. diff was negative on two
samples. This development was thought to be related to her tube
feeding, which was adjusted. She received a PEG tube on [**12-4**]. On discharge, her examination was noted as follows: "stable
LUE and LLE paresis. Stable eyelid apraxia. Minimally responsive
to touch or voice. Rare vocalizations yes/no."
Review of Systems:
Given her somnolence and inattention, the patient was unable to
reliably answer questions posed to her.
Past Medical History:
CAD s/p MI and proximal LAD taxus stent
HTN
HLD
hypothyroidism
left knee sx
Social History:
Lives at home with husband
Family History:
Noncontributory
Physical Exam:
General: elderly woman lying sprawled across stretcher, trying
to
remove her blankets
HEENT: NC/AT, sclerae anicteric, dry MM, no noted exudates in
oropharynx
Neck: no nuchal rigidity, but moves neck actively reducing
ability to assess on passive range of motion, no bruits
Lungs: reduced breath sounds on poor effort, but clear to
auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: PEG in place, site C/D/I, soft, non-tender,
non-distended
Ext: cool, no edema, pedal pulses appreciated
Skin: pale
Neurologic Examination:
Mental Status:
Has eyes closed, though able to open on command at first. For
much of the interview, she actually closes her eyes on request
of
opening as I attempt to assess them. She does not follow other
commands and does appear somewhat inattentive and somnolent
(even
accounting for the previously reported eyelid apraxia). She
seems to be moving around restlessly in the bed.
Cranial Nerves:
Could not assess fundi as patient actively closed eyes on
attempts to examine; there is no clear deficit of visual fields
on blink to threat. Pupils equally round and reactive to light,
4 to 3 mm bilaterally. Moves eyes to left and right
spontaneously, but does not follow commands for assessment of
vertical gaze, no nystagmus seen. Left facial weakness noted in
lower face. Hearing intact to finger rub bilaterally. Palate
elevates midline and tongue protrudes midline on yawn.
Sensorimotor:
Normal bulk and though tone seems increased in the left side,
more so in the arm than in the leg. No tremor or adventitious
movements seen. The patient is too inattentive to participate
in
full formal strength testing. She is moving the right side
spontaneously and against gravity, and is able to demonstrate
near full strength in the biceps and triceps on the right. On
her left, she spontaneous is flexing her hip anti-gravity to
raise her knee off the bed. She appears to have some minimal
movement in the left arm, perhaps ~2-/5. She withdraws all
extremities to noxious, right side more than left. Her left leg
withdraws far more briskly than her left arm.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 0
Left 3 2 3 3 0
Toes were upgoing bilaterally. Has grasp reflex on the right.
The patient was unable to participate in coordination and gait
testing.
Pertinent Results:
[**2120-12-30**] 03:54PM PT-14.9* PTT-26.4 INR(PT)-1.3*
[**2120-12-30**] 03:54PM PLT COUNT-419
[**2120-12-30**] 03:54PM NEUTS-77.8* LYMPHS-16.4* MONOS-3.4 EOS-2.0
BASOS-0.4
[**2120-12-30**] 03:54PM WBC-9.9 RBC-4.11* HGB-12.4 HCT-36.7 MCV-89
MCH-30.2 MCHC-33.8 RDW-14.0
[**2120-12-30**] 03:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-5.2
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2120-12-30**] 03:54PM PHENYTOIN-19.4
[**2120-12-30**] 03:54PM T3-63* FREE T4-1.1
[**2120-12-30**] 03:54PM TSH-23*
[**2120-12-30**] 03:54PM ALBUMIN-4.0 CALCIUM-9.4 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2120-12-30**] 03:54PM CK-MB-7
[**2120-12-30**] 03:54PM CK-MB-7
[**2120-12-30**] 03:54PM UREA N-19 CREAT-0.6 SODIUM-138 POTASSIUM-3.2*
CHLORIDE-97 TOTAL CO2-33* ANION GAP-11
[**2120-12-30**] 04:00PM URINE RBC-[**11-28**]* WBC->1000 BACTERIA-MANY
YEAST-NONE EPI-0
[**2120-12-30**] 04:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2120-12-30**] 06:44PM LACTATE-1.2
[**2120-12-30**] 09:19PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-12-30**] 09:19PM URINE HOURS-RANDOM
[**2120-12-30**] 09:52PM CK-MB-8 cTropnT-<0.01
[**2120-12-30**] 09:52PM CK(CPK)-452*
[**2120-12-31**] Head CT IMPRESSION:
1. Unchanged appearance of right parietooccipital parenchymal
hematoma with an old evolving right parasagittal frontal
hematoma; this overall appearance is suggestive of underlying
amyloid angiopathy. Persistent mass effect.
2. Disproportionate temporal [**Doctor Last Name 534**] dilatation suggests more
severe
medial temporal atrophy, raising the concern for Alzheimer's
disease (which may be associated with amyloid angiopathy).
3. No evidence of new hemorrhage.
[**2121-1-1**] Head CT - IMPRESSION:
1. No new hemorrhage or fracture.
2. No significant interval changes, with the known
intraparenchymal hemotomas, peri-hemorrhagic edema and mass
effect as described above.
Brief Hospital Course:
Pt was admitted to the ICU for management of her ICH.
Neuro: Serial Head CT were obtained to monitor progression of
her ICH. Pt was initially started on dilantin for seizure
prophylaxis then it was discontinued on [**1-1**].
ID: UTI She was noted to have a UTI. Ucx Enterococcus and
10K-100K E.coli. Pt initially started on Vanco and CTX IV Abx
then switched to PO cephalosporin on the day of discharge for an
additional 3 days to complete her course.
ENDO: Hypothyroidism Hypothyroidism was known prior to admission
yet TSH and free T4 values were obtained to show a need for
additional thyroixine supplementation. Her levothyroxine was
increased from 88mcg to 112mcg prior to d/c.
Medications on Admission:
Atorvastatin 80 mg po daily
-Acetaminophen 325 mg tablet, 1-2 Tablets every 6 hours as
needed
for fever, pain
-Memantine 10 mg daily
-Levothyroxine 88 mcg daily
-Amlodipine 2.5 mg daily
-Lisinopril 20 mg daily
-Senna 8.6 mg [**Hospital1 **] as needed for constipation
-Docusate Sodium 50 mg/5 mL 100 mg [**Hospital1 **]
Discharge Medications:
1. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ASDIR (AS DIRECTED).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
3. Senna 8.8 mg/5 mL Syrup Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q 6
HOURS PRN FOR SYSTOLIC BLOOD PRESSURE GREATER THAN 160 ().
10. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Right frontal hemorrhage
Amyloid Angiopathy
Hypothyroidism
Right frontal hemorrhage, as discussed above
-s/p PEG placement [**12-4**]
-Coronary artery disease s/p MI with prox LAD taxus stent
-Hypertension
-Dyslipidemia
-s/p left knee surgery
Discharge Condition:
Stable. Eyelid apraxia, Left hemiparesis (leg>arm), Left
hyperreflexia, and upgoing toe. UTI.
Discharge Instructions:
You have come in for an intracranial hemorrhage/brain bleed.
This was most likely due to amyloid angiopathy. For this reason
you should not be placed on aspirin now or in the future without
this being mentioned.
You also have an UTI you will be sent out with 3 days of oral
antibiotics.
Also your thyroid medication has been increased from 88mcg to
112mcg. You TSH and Free T4 should be checked by your PCP [**Last Name (NamePattern4) **]
4-6weeks and adjust accordingly.
Return to the ER if your symptoms recur, you have persistent
nausea and vomiting or any motor deficits.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2121-1-22**] 1:00
PCP [**Name Initial (PRE) 176**] 1-2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"412",
"414.01",
"041.04",
"784.69",
"431",
"401.9",
"244.9",
"041.4",
"272.4",
"277.39",
"V45.82",
"599.0",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10132, 10210
|
8200, 8886
|
350, 357
|
10497, 10593
|
6237, 8177
|
11220, 11542
|
3878, 3895
|
9257, 10109
|
10231, 10476
|
8912, 9234
|
10617, 11197
|
3910, 4418
|
3611, 3717
|
276, 312
|
385, 3592
|
4843, 6218
|
4457, 4827
|
4442, 4442
|
3739, 3817
|
3833, 3862
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,079
| 180,684
|
27225
|
Discharge summary
|
report
|
Admission Date: [**2167-8-23**] Discharge Date: [**2167-9-10**]
Service: SURGERY
Allergies:
Pronestyl / Clindamycin / Coumadin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
"I need a colonoscopy"
Major Surgical or Invasive Procedure:
[**8-24**] Colonoscopy
[**8-25**] EGD with push enteroscopy
[**8-25**] Exploratory laparotomy with right hemicolectomy
History of Present Illness:
[**Age over 90 **] yo female with a h/o CHF and anemia, who presents for bowel
prep for a colonoscopy tomorrow AM. She reportedly has guaiac
positive stools, but colonoscopy has not been completed [**1-29**] pt
vomiting contrast material. She notes that she can eat solids
and liquids, but the rate at which she can swallow is her
limiting factor. Unclear what her baseline Hct is, but she has
recently been hospitalized for CHF/PNA/"severe" anemia in
[**Month (only) 404**] and again [**2167-1-28**] at [**Hospital3 **] Hospital. She
states that she does get "dizzy" with standing abruptly, and has
fallen multiple times, but mostly [**1-29**] decreased vision as
opposed to orthostasis. She has had DOE for years, stable, able
to walk half a mile or 1 flight of stairs before getting short
of breath. No chest pain or pedal edema. On ROS, no
constipation/diarrhea/melena/BRBPR/fever/chills/night
sweats/PND/orthopnea/incontinence or other urinary symptoms.
Past Medical History:
Pacemake placed >25 years ago
L Carotid stent placed 5-10 years ago
Open heart surgery in 50s for VSD
Has "lazy valve" per report
Gout in [**2167**] resolved with ibuprofen
Social History:
Pt lives with her daughter in [**Name (NI) **] in [**Hospital3 **] on the
weekends, and in [**Last Name (un) **] on the weekends at home. Has 2 cats and
1 dog. Drinks 1.5 cups of whiskey+soda daily, no smoking/IVDU
Family History:
No family h/o CA, DM, heart disease
Physical Exam:
T 98.5 BP 170/70 P 72 RR 20 93% O2 Sats RA
Gen: Pleasant woman in NAD, appears younger than stated age
HEENT: Clear OP, MMM, L surgical pupil, R pupil reactive at 1
cm, vision impaired bilaterally; can detect light and large
objects.
NECK: Supple, No LAD, JVP at 8-10 cm, No bruits
CV: RR, NL rate. NL S1, S2. Early diastolic murmur loudest over
apex
LUNGS: bibasilar fine crackles
ABD: Soft, NT, mild epigastric tenderness to deep palpation. NL
BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2167-8-23**] 03:45PM WBC-10.5 RBC-3.96* HGB-11.2* HCT-34.1* MCV-86
MCH-28.2 MCHC-32.7 RDW-15.4
[**2167-8-23**] 03:45PM PLT COUNT-310
[**2167-8-23**] 03:45PM PT-12.6 PTT-26.6 INR(PT)-1.1
[**2167-8-23**] 05:10PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-2.8
MAGNESIUM-1.8
[**2167-8-23**] 05:10PM LIPASE-29
[**2167-8-23**] 05:10PM ALT(SGPT)-35 AST(SGOT)-48* ALK PHOS-91
AMYLASE-77 TOT BILI-0.5
[**2167-8-23**] 05:10PM GLUCOSE-546* UREA N-23* CREAT-0.8 SODIUM-134
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-28 ANION GAP-12
[**2167-8-23**] 05:10PM BLOOD Lipase-29
[**2167-8-23**] 05:10PM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.8 Mg-1.8
Pre-operative Labs:
[**2167-8-25**] 10:37PM BLOOD WBC-12.7* RBC-3.60* Hgb-10.3* Hct-31.1*
MCV-87 MCH-28.6 MCHC-33.1 RDW-15.4 Plt Ct-301
[**2167-8-25**] 03:50PM BLOOD Neuts-85* Bands-5 Lymphs-7* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2167-8-25**] 10:37PM BLOOD PT-13.3* PTT-26.8 INR(PT)-1.2*
[**2167-8-25**] 10:37PM BLOOD Glucose-91 UreaN-30* Creat-1.4* Na-142
K-3.6 Cl-101 HCO3-25 AnGap-20
[**2167-8-25**] 10:37PM BLOOD CK(CPK)-59
[**2167-8-25**] 10:37PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2167-8-25**] 10:37PM BLOOD Calcium-8.3* Phos-4.8*# Mg-1.5*
Discharge Labs:
[**2167-9-8**] 03:15AM BLOOD WBC-14.5* RBC-2.69* Hgb-8.0* Hct-23.6*
MCV-87 MCH-29.6 MCHC-33.9 RDW-17.3* Plt Ct-444*
[**2167-9-8**] 03:15AM BLOOD PT-12.6 PTT-24.0 INR(PT)-1.1
[**2167-9-8**] 03:15AM BLOOD Plt Ct-444*
[**2167-9-8**] 03:15AM BLOOD Glucose-57* UreaN-27* Creat-1.0 Na-142
K-3.6 Cl-105 HCO3-28 AnGap-13
[**2167-9-8**] 03:15AM BLOOD Phos-3.1 Mg-1.7
[**2167-9-8**] 03:26AM BLOOD Type-[**Last Name (un) **] pH-7.36 Comment-GREEN TOP
[**2167-9-8**] 03:26AM BLOOD freeCa-1.11*
Microbiology:
[**2167-8-25**] 5:50 pm SWAB Site: PERITONEAL REC'D AT 11:30
PM.
GRAM STAIN (Final [**2167-8-27**]):
[**2167-8-26**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1052**] [**Last Name (NamePattern1) 5259**] AT 4:00 AM.
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
aureus and beta streptococcus).
GRAM NEGATIVE ROD(S).
MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
[**2167-8-31**] 9:52 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2167-9-3**]**
MRSA SCREEN (Final [**2167-9-3**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin sensitivity performed by agar screen.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
OXACILLIN------------- R
[**2167-8-31**] 9:49 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2167-9-3**]**
GRAM STAIN (Final [**2167-8-31**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2167-9-3**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
[**2167-9-7**] 3:49 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
[**2167-9-7**] 3:49 pm SWAB Site: RECTAL
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Preliminary): No VRE
isolated.
CT CHEST W/CONTRAST [**2167-8-25**] 4:33 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: please evaluate for perforation
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with severe abdominal pain s/p colonoscopy.
REASON FOR THIS EXAMINATION:
please evaluate for perforation
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: CT abdomen.
INDICATION: Severe abdominal pain post-EGD.
FINDINGS: A CT of chest and abdomen was performed with axial
images taken from the lung apices to the symphysis pubis. IV
contrast only was administered.
On the CT of thorax there is some soft tissue in the apices
bilaterally which may represent apical scarring.
This patient has a pacemaker with two leads in situ.
The pulmonary arteries are very large and the left atrium is
also prominent. The appearances may be consistent with pulmonary
hypertension.
The patient has cardiomegaly.
On the lung windows there is emphysematous change in the lungs
and some scattered scarring.
Anterior to the distal esophagus there is some free air.
Below the diaphragm air is seen to extend along the posterior
part of the caudate lobe and along the falciform ligament. Free
air is also seen anterior to the left lobe of the liver. More
inferiorly free air is seen posterior to the tip of the right
lobe of the liver.
There is intrahepatic bile duct dilatation. The common bile duct
measures 1 cm. The appearances may be consistent with the
patient's age.
The spleen is normal.
The adrenals and kidneys are unremarkable.
The bowel where visualized is normal.
CT PELVIS: Some free fluid is seen in the pelvis and extending
to the right side of the rectum. Several diverticula are seen in
the sigmoid colon.
BONY WINDOWS: Degenerative changes noted throughout the spine.
There is a high-density medium in the spinal canal which may
represent previous Thorotrast examination.
IMPRESSION:
Status post perforation from recent examination most likely
secondary to EGD. Free air seen extending into the mediastinum
from the inferior esophagus and extending down into the abdomen
around the liver and into the falciform ligament.
Bilateral pleural effusions and atelectasis. Biapical scarring
and emphysema. Cardiomegaly and enlarged pulmonary arteries
which may be secondary to pulmonary hypertension.
Diverticula in the sigmoid colon. Free fluid in the pelvis.
Degenerative change in the spine.
Intra- and extra-hepatic bile duct dilatation.
Possible Thorotrast exposure in the spinal canal.
Cardiology Report ECHO Study Date of [**2167-8-27**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Valvular heart disease.
Height: (in) 62
Weight (lb): 104
BSA (m2): 1.45 m2
BP (mm Hg): 108/35
HR (bpm): 60
Status: Inpatient
Date/Time: [**2167-8-27**] at 09:19
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W000-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.1 cm
Left Ventricle - Fractional Shortening: 0.51 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec)
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - E Wave: 1.6 m/sec
Mitral Valve - E Wave Deceleration Time: 566 msec
TR Gradient (+ RA = PASP): *50 to 60 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: *1.2 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing
wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall
hypokinesis.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Characteristic rheumatic deformity of the mitral valve leaflets
with fused
commissures and tethering of leaflet motion. Moderate thickening
of mitral
valve chordae. Moderate MS. Mild to moderate ([**12-29**]+) MR.
TRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic
hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Left pleural effusion.
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
3. The right ventricular cavity is moderately dilated. There is
severe global
right ventricular free wall hypokinesis.
4. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is
not present. Mild (1+) aortic regurgitation is seen.
5. The mitral valve leaflets are severely thickened/deformed.
The mitral valve
shows characteristic rheumatic deformity. There is moderate
thickening of the
mitral valve chordae. There is moderate mitral stenosis. Mild to
moderate
([**12-29**]+) mitral regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension.
OPERATIVE REPORT
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 66760**]
Service: Date: [**2167-8-25**]
Surgeon: [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], MD 2205
PREOPERATIVE DIAGNOSIS: Perforated viscus.
POSTOPERATIVE DIAGNOSIS: Perforation of the right colon.
SURGICAL PROCEDURE: Laparotomy, right colectomy and
abdominal washout.
ASSISTANT: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD (RES)
ANESTHESIA: General.
INDICATIONS: This elderly woman has undergone 2 endoscopic
procedures with therapy in 2 days. These have included a
colonoscopy with BICAP of angiodysplastic lesions in the
cecum, as well as removal of a sigmoid polyp. On the
following day, she had a push enteroscopy with BICAP of
several lesions in her stomach. She originally did well, but
then developed the sudden onset of abdominal pain and had
free air under the diaphragm, confirmed both by upright chest
x-ray and CT scan. She is complaining of abdominal pain with
tenderness and has been given the option of surgical
treatment. At [**Age over 90 **] years old, she does wish to undergo surgery,
as there is a reasonable chance of fixing the problem.
PREPARATION: In operating room, the patient was given a
general endotracheal anesthetic. Intravenous antibiotics were
given, 2 grams of heparin and boots. The abdomen was prepared
with Betadine solution and draped in the usual fashion.
INCISION: A midline incision was made incorporating a
portion of the old lower midline incision with another upward
extension part way up between the umbilicus and the xiphoid.
The abdomen then opened and explored.
FINDINGS: There was a pneumoperitoneum. There were some
adhesions from her old surgery in the midline. There were
also adhesions from her cholecystectomy to the liver. There
was purulent fluid in the abdomen, a small but modest amount.
There was a small amount of free stool spillage from a tiny
perforation of the right colon. There was another perforation
which was even smaller, a centimeter or two away, in the
right colon. There were no other perforations that we could
see.
PROCEDURE IN DETAIL: The abdomen was opened. The adhesions
were lysed. We were able to suck out purulent fluid and find
the perforation in the cecum, which was closed over with silk
suture. The abdomen was then irrigated copiously after
control of the spill was accomplished. We also ran the bowel
and found several small diverticula of the small bowel which
were totally intact. There was no injury to the small bowel.
There did not appear to be any problem with the stomach. The
sigmoid colon also appeared to be normal, although there were
some adhesions down to the pelvis.
It was my feeling that the best therapy here would be a right
colectomy, in that the patient had a diseased right colon to
begin with, and the cause of the bleeding most likely. It
also appeared to be relatively thin walled and I was worried
that if I had oversewn the 2 areas where there were
perforations present now, that some of the other treated
areas, of which there were approximately 10, might become
problem[**Name (NI) 115**] in the next several days. Therefore, we mobilized
the right colon at the white line of Toldt. The hepatic
flexure was taken down. The omentum was taken off the
transverse colon. We selected our resection margin, taking
only approximately 3 or 4 inches of terminal ileum. We then
extended our resection down well around to the mid transverse
colon, in order to ensure that we had gotten all of the areas
of vascular malformation seen in the descending and ascending
colon. Bowel was cleaned off and [**Female First Name (un) 3224**] stapler was applied
across both the ileum and the colon. Mesentery was then taken
between clamp with 2-0 silk ties. The specimen was sent off
the field. Due to the lateness of the hour, it was not open.
We then oversewed the staple line with interrupted sutures of
3-0 silk. A side-to-side anastomosis was then created using
interrupted 3-0 silk in a single layer. The posterior row was
placed of sutures of 3-0 silk and then tied down. The colon
and ileum were then opened and the anterior row was placed.
The neck of the anastomosis was quite wide and spacious.
There was no evidence of leak. It was noted that gas and
liquid stool would pass without problem. The mesentery was
then closed with the 3-0 silk. The areas were inspected and
were dry.
CLOSURE: The fascia was closed with a running suture of #1
PDS. The skin was closed with a stapling device. Dry sterile
dressings were applied. The patient was then extubated and
sent to the recovery area in satisfactory condition, having
tolerated the procedure well.
DRAINS: None.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
Brief Hospital Course:
Ms. [**Known lastname 4427**] had been admitted to [**Hospital1 18**] on [**8-23**] under the medical
service for a colonoscopy secondary to her inability to tolerate
the oral contrast and a history of congestive heart failure and
anemia, along with her age of [**Age over 90 **] years. The colonoscopy
demonstrated multiple diverticula and angioectasias which were
cauterized. It was recommended that she undergo an enteroscopy
and be placed on iron replacement therapy. The small bowel
enteroscopy was performed on [**8-25**] which showed gastric
angioectasias that were cauterized and duodenal diverticula.
She developed acute abdominal pain with peritoneal signs after
her small bowel enteroscopy. An abdominal x-ray showed free air
under the diaphragm. An abdominal and pelvic CT scan was done
which showed free intraperitoneal air and perforation. The
surgical service was consulted and she was taken to the
operating room under the care of Dr. [**Last Name (STitle) **] for an
exploratory laparotomy and right hemicolectomy on [**8-25**]. She was
started on intravenous Zosyn and Flagyl pre-operatively and gram
negative rods were found on a peritoneal swab intra-operatively
and continued for a total of fourteen days. Ampicillin was added
on POD 4 after a nasal swab confirmed Staph Aureus Coag + and
was completed after four days of treatment and a repeat culture
showing no growth.
Post-operatively she developed low urine output and hypotension
and was admitted to the surgical intensive care unit. Her
creatinine was found to be elevated at 1.7 which was thought to
be related to the CT scan contrast. On POD 2 a Levophed drip was
started to maintain her systolic blood pressure greater than 110
and a renal consultation was initiated. The renal service
recommended more intravenous resuscitation and then challenging
with Lasix. An echocardiogram was also done in the setting of
her history of congestive heart failure, her central venous
pressures of 16 and low urine output. This showed her systolic
function to be >55% along with mild pulmonary hypertension,
tricuspid, and mitral regurgitation. On POD 3 her respiratory
status deteriorated and she was not tolerating continous
positive airway pressure via a face mask. An arterial blood gas
demonstrated respiratory and metabolic acidosis. A chest x-ray
confirmed pulmonary edema. She had persistent anuria after
Lasix, Bumex, and intravenous fluids. Hemodialysis was also
started on POD 3 by the renal service after her persistent
anuria and a creatinine of 3.7. After discussion with her
family, the patient's advanced orders of not intubating were
rescinded but the order of no resuscitation with chest
compressions was maintained, she was intubated and mechanically
ventilated on POD 3.
A Dobbhoff feeding tube was placed on POD 5 and tube feeds were
started. On POD 6 the dialysis was stopped secondary to an
increase in urine output but was resumed on POD 7 after her
weight was noted to have increased, she was anuric, and
pulmonary failure was noted on chest x-ray. The Levophed drip
continued along with mechanical ventilation. On POD 6 and 7 she
was transfused a total of two units of packed red blood cells
for a hematocrit of 24 and 21 with no active signs of bleeding,
with a good response in her hematocrit. On POD 9 the Levophed
was discontinued and hemodialysis was stopped secondary to
improvement in her renal function; her serum creatinine was 0.7,
and her urine output was satisfactory. On POD 10 she was
successfully extubated.
POD 12 a diet was resumed, she remained afebrile, and her
central venous catheter was removed secondary to an increased
white blood cell count of 15.5k; the tip was cultured with no
growth found. Diuresis continued with daily Lasix with a good
response in her urine output. On HD 13 her Dobbhoff was removed
and she was tolerating a regular diet. At the time of discharge
she was afebrile, oxygenating well on 3 liters nasal cannula,
tolerating a regular diet with +bowel movements and +flatus. She
had completed her antibiotic course and her white blood cell
count was stable at 12.9k. On HD18, she had an episode of
hypoglycemia (40 mg/dl). Her insulin was held, she was given
glucose, and she recovered without incident. The Lasix was
continued daily with the dose decreased from 40mg to 20mg, her
BUN was 29 with a creatinine of 0.9. She was hemodynamically
stable at the time of discharge with a hematocrit of 25.2. She
was transferred to [**Hospital1 599**] of [**Hospital 23638**] rehabilitation facility for
further strength and mobility training.
Medications on Admission:
Lorazepam 0.5 mg PO HS:PRN anxiety
Multivitamins 1 CAP PO DAILY
Atorvastatin 10 mg PO HS
Digoxin 0.125 mg PO DAILY
Furosemide 40 mg PO DAILY
Trandolapril 8 mg PO DAILY
Occuvite
Nexium 40
Plavix 75 (held)
Calcium qd
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).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Other Sig: Zero (0) every six (6) hours: Fingersticks to
be done every 6 hours with Regular Insulin Sliding Scale.
9. Lasix 20mg Tablet Sig: One (1) Tablet PO once a day.
10. Acetaminophen 500 mg/5 mL Liquid Sig: One (1) PO every six
(6) hours as needed for pain: Dose should equal 650mg or 6.5ml.
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Lorazepam 0.5 mg PO QHS for insomnia
Discharge Disposition:
Extended Care
Facility:
Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**]
Discharge Diagnosis:
Anemia
Perforated bowel
Discharge Condition:
Good
Discharge Instructions:
Notify your MD or return to the emergency department if you
experience:
*Increased or persistent pain
*Fever > 101.5
*Nausea or vomiting
*Inability to pass gas or stool
*If incision appears red, is warm, or if there is drainage
*Any other symptoms concerning to you
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, call ([**Telephone/Fax (1) 8818**] for an appointment
|
[
"569.85",
"398.91",
"584.9",
"276.2",
"V45.01",
"537.82",
"285.1",
"492.8",
"998.2",
"396.3",
"211.3",
"427.31",
"E878.8",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.41",
"46.75",
"45.73",
"96.04",
"38.93",
"45.42",
"45.43",
"96.72",
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] |
icd9pcs
|
[
[
[]
]
] |
22623, 22722
|
16787, 21371
|
264, 385
|
22790, 22797
|
2616, 2616
|
23113, 23234
|
1818, 1855
|
21637, 22600
|
6296, 6374
|
22743, 22769
|
21397, 21614
|
22821, 23090
|
3845, 6259
|
8719, 16764
|
1870, 2597
|
202, 226
|
6403, 8693
|
413, 1373
|
2633, 3828
|
1395, 1570
|
1586, 1802
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,135
| 101,229
|
51230
|
Discharge summary
|
report
|
Admission Date: [**2163-4-15**] Discharge Date: [**2163-4-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
86 y/o f c/ CHF EF 25%, CAD, ESRD on HD M/W/F, woke from sleep
with increased SOB and worsening cough. She reports 3 days of
increasing cough and sputum production. CXR at her nursing home
2 days ago was consistent with PNA and oral antiobiotics were
initiated.
She denies any chest pain, palpitations, fevers, chills, or
nightsweats with these symptoms. She has noted lower extremity
edeam which is not baseline for her and [**2-8**] loose stools/day
since initiation of antibiotics. She is due for her regularly
scheduled hemodialysis today. Despite initiation of abx her
cough worsened, she also vomited qam x 2 days [**2-7**] coughing 3
days PTP- non bloody, non-bilious emesis. No sick contacts. Does
not report further diarrhea. No constipation, no dysuria. No
arthralgias.
.
In ED, vitals were T98.3 HR93 BP129/78 RR32 POx99. Sats 88% RA
on arrival and improved with 2 nebs to 96% 4L with ABG
7.43/47/74.
Patient received albuterol/ipratropium nebs, levofloxacin 750mg
IV, Methylprednisolone 125mg IV, 1gm ceftriaxone, 1gm
vancomycin. Lactate 1.7. Patient was transferred to the [**Hospital Unit Name 153**] for
tachypnea.
.
On arrival to the [**Hospital Unit Name 153**], patient was comfortable reporting
significant improvement since receiving nebulizer treatment in
the ED. She continues to report cough but denies SOB, DOE,
nausea, vomiting, CP, fevers, chills, pleuritic pain, abdominal
pain, dysuria.
.
In the [**Hospital Unit Name 153**] the patient received broad spectrum abx and
nebulizers. With that her O2 requirement decreased and her
respiratory status improved. She also underwent regularly
scheduled HD on the day of transfer during which 2 kg of fluid
was removed.
Past Medical History:
Coronary Artery Disease with Coronary artery bypass graft x 3
[**2162-8-16**] (LIMA-LAD, SVG-OM, SVG-PDA)
Mitral valve annuloplasty [**2162-8-16**]
Systolic CHF (LVEF 30% on TTE [**2162-8-27**])
Chronic Kidney Disease
Hyperlipidemia
Hypertension
Gout
Diverticulosis
Depression
Status post choleycystectomy
Status post hernia repair
Status post hip fracture repair
Social History:
She is a retired travel [**Doctor Last Name 360**]. She recently quit smoking but
previously smoked one pack per week for 70 years. She denies
alcohol use. No illicit drug use. She is now coming from rehab
but previously lived with her husband until he had an MI. She
has two children [**Location (un) 86**] and [**Hospital1 614**] who are very involved.
Family History:
Mother had hypertension. Father had hypertension and CVA. No
family history of cardiac disease or sudden cardiac death.
Physical Exam:
Presentation
VS: Temp = 96.2F, BP = 116/61, HR = 68, RR = 28, 97% on 2L
GENERAL - chronically ill-appearing elderly female comfortable,
speaking in full sentences, appropriate. Good recall of events.
She can clearly tell me about her PMH. No evidence of delirium.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMD, lower
dentures in place
NECK - supple, appears elevated but difficult to assess JVD [**2-7**]
right IJ HD catheter
LUNGS - patient refused to let me listen to her lungs- tired
HEART - HS distant, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, pitting edema b/l to just below knees, 1+
peripheral pulses (radials, DPs), left heel exophytic ulceration
4x5 cm unable to stage without drainage
SKIN - 1x1cm 0.5cm deep sacral decubitus ulcer, no drainage -
per ICU note
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-10**] throughout, sensation grossly intact throughout
Contracted lower extremities.
Pertinent Results:
CXR: [**4-11**] [**2163**]- cardiolmegaly, CHF, RLL infiltration from NH
.
[**2163-4-15**] CXR - b/l pleural effusion, bibasilar atelectasis and
dense retrocardiac opacity, atelectasis vs. pneumonia, right
hilar fullness, recommend f/u w/ PA/L to further evaluate hilar
fullness, cardiomegaly baseline
.
[**10-13**] TTE:
Normally-functioning mitral annuloplasty ring. Severe regional
left ventricular systolic dysfunction, c/w multivessel CAD.
Moderate pulmonary hypertension.
.
[**2163-4-15**] EKG: NSR 88, Nl axis, IVCD, t-wave inversion in V6
isolated as compared with old [**2162-10-15**].
<br>
[**2163-4-15**] 06:00PM CK(CPK)-26
[**2163-4-15**] 06:00PM CK-MB-3 cTropnT-0.10*
[**2163-4-15**] 09:13AM TYPE-ART RATES-/33 PO2-75* PCO2-47* PH-7.43
TOTAL CO2-32* BASE XS-5 INTUBATED-NOT INTUBA
[**2163-4-15**] 06:51AM LACTATE-1.7
[**2163-4-15**] 06:10AM GLUCOSE-109* UREA N-30* CREAT-4.0* SODIUM-139
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-19
[**2163-4-15**] 06:10AM CK(CPK)-25*
[**2163-4-15**] 06:10AM cTropnT-0.10*
[**2163-4-15**] 06:10AM CK-MB-NotDone proBNP-[**Numeric Identifier 106286**]*
[**2163-4-15**] 06:10AM ALBUMIN-3.2*
[**2163-4-15**] 06:10AM WBC-7.3 RBC-3.48*# HGB-11.6*# HCT-36.7#
MCV-106* MCH-33.2* MCHC-31.5 RDW-16.4*
[**2163-4-15**] 06:10AM NEUTS-90.7* LYMPHS-6.4* MONOS-1.7* EOS-1.2
BASOS-0
[**2163-4-15**] 06:10AM PLT COUNT-120*
<br>
PA AND LATERAL CHEST, [**4-16**].
.
HISTORY: End-stage renal disease and CHF with shortness of
breath.
.
IMPRESSION: PA and lateral chest compared to [**8-15**]:
.
Mild interstitial edema has cleared from the left lung, persists
at the right base. Lateral view shows small right pleural
effusion collected posteriorly. Moderate cardiomegaly
unchanged. No pneumothorax. Dialysis catheter ends in the SVC.
<br>
CXR [**4-17**]:
REASON FOR EXAM: CHF and tachypnea.
.
Comparison is made with prior studies [**4-15**] and 11.
.
Moderate cardiomegaly is unchanged. Mild interstitial pulmonary
edema is
unchanged, asymmetric and greater on the right side.
Small-to-moderate
bilateral pleural effusions are increased on the right side.
Retrocardiac
opacity is consistent with atelectasis. Right supraclavicular
catheter is in place. Sternal wires are aligned. The patient is
status post MVR.
Brief Hospital Course:
86 y/o f c/ CHF, CAD, ESRD on HD presenting from nursing facilty
with SOB and worsening cough x5 days admitted to [**Hospital Unit Name 153**] with
concern for respiratory distress. Hospital Course as below:
<br>
#. Respiratory Distress - sx improving as of am of [**4-16**], CXR
demonstrating retrocardiac opacity consistent with PNA and b/l
pleural effusions, with repeat CXR [**4-16**] showing improvement but
persistant R base findings - cont tx for PNA. Etiology likely
multifactorial in setting of CHF, ESRD on HD and PNA. Improved
after starting on Abx and particularly especially w/ regularly
scheduled HD with improved volume status. Overall, CXR
suggestive more of R-sided PNA after fluid taken out - plan to
cont abx. Noted events with increased SOB sx overnight [**4-16**] -
overall pt 1.6L positive for [**4-16**] - mildly increased fluid on
exam/CXR - with PNA process pt with lower threshold for fluid as
prior - in addition with noted upper resp secretions - declined
deep suctioning, but improved with mucolytics agents and with
min secretions as of [**4-18**]. Pt recieved HD [**4-18**] - doing well
following - plan to complete 8 day course of antiobiotic
(finishing [**4-22**]) - changed to po cefopodixime today, cont IV
vanc post HD).
- HD as below, (noted pt can only make scant urine)
- decreased fluid intake [**4-17**] - pt doing better
- change nebs to q6h PRN
- cont mucomyst nebs and guaifensin to [**Month/Year (2) **] w/ secretions for
next 2 days - can then change to just PRN
- origninally treated for for healthcare associated PNA,
especially as known MRSA, was treated with broad spectrum abx
with report failed to fluroquinolone prior - it was confirmed
that the abx was levoquin (started [**4-11**]) - based on this d/c
levoquin as of [**4-16**]
- unable to obtain adequate sputum cx - tx as above
<br>
#. Acute on Chronic systolic Heart Failure - EF 25% at baseline,
appears volume overloaded on exam (fluctuates with HD). W/ Known
pulm HTN likely exacerbated by underlying pulmonary infectious
process. Cardiac enxymes below baseline, BNP elevated.
- manage volume status w/ HD
- continue aspirin, statin, BB
- ruled out for ACS
- d/c to NH today
- ***noted pt will have extra volume taken of at HD tomorrow -
renal service here had communicated this with her outpt center
so will proceed as such tomorrow
<br>
#. ESRD on HD - M/W/F
- HD done yesterday, cont prior regime - with Vanc IV to be
given post HD AND po cefopodoxime 200mg to be given after (2
more doses pending for W and F HD
-as above, - ***noted pt will have extra volume taken of at HD
tomorrow - renal service here had communicated this with her
outpt center so will proceed as such tomorrow
<br>
#. Skin Breakdown - has heel and sacral decub on admission
- wound care to heel as recommended by wound care nurse - needs
close monitoring and follow-up - clears recs per d/c
summary/instructions
- wound care to sacral decub per recs
- alb noted 2.8
<br>
Vascular wounds:
Pt refused a thorough exam thus difficult to assess if she has
PVD wounds as per dtr. Dtr wanted pt to be seen by vascular
surgery while in house since she has an appt with Dr. [**Last Name (STitle) 2716**] on
Tuesday. As pt in-house on [**4-19**] - pt will be d/c and sent to
clinic appt and transported to NH following
<br>
#. h/o Afib - currently rhythm and rate controlled
- continue amiodarone, BB, aspirin
<br>
#. Depression - continue home mirtazipine/citalopram
<br>
# thrombocytopenia - mildly lower than mid 100s baseline - hep
sc d/c [**4-17**] - mildly improved on [**4-18**] to 98 from 83. Given
improvement - can be monitored more as outpt unless clinical
situation changes.
<br>
#. FEN - low Na/cardiac/renal diet, manage lytes with HD, low
phos diet
.
#. Access - PIV
.
#. PPx -
-DVT ppx changed as above to scds
-Bowel regimen prn
-Pain management with tramadol
-GI prophylaxis with home PPI
.
#. Code - FULL - Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - [**Telephone/Fax (1) 106287**]
Note following discussion per nocturnist on admission to medical
floor [**4-16**]: Spoke to dtr for 30 [**Name2 (NI) **] on admission. Dtr
initially very upset to be called in the middle of the morning.
[**Name8 (MD) **] RN children have been abusive to ICU staff as well. Dtr
apologized for outburst and said that she understands that we
are trying to give her mother good care but she is an
overwhelmed caregiver.
.
With regards to code status- she was DNR/DNI but she had to
reverse it to have her sternal wound repaired. She thinks her
mother would not want to be a full code and would like to be
DNR/DNI.
.
# Contact: [**Name (NI) **] [**Last Name (NamePattern1) **]-PLEASE DO NOT CALL EARLY IN THE
MORNING OR LATE AT NIGHT.
.
Disposition: pt medically improved now and stable - pt to be d/c
now and sent to outpt vasc [**Doctor First Name **] appointment then to be
transferred back to nursing home - pt was not d/c [**4-18**] due to
prior NH not accepting pt back due to prior financial obstacles
and no safe disposition was available - daughter informed - able
to work out problem - pt accepted again today - and able to be
d/c back to NH
Medications on Admission:
Accuzyme topical dosage unknown
albuterol solution Q4-6 hours prn
Amiodarone 200mg daily
Aspirin 81mg daily
Calcitriol 0.25mg QOD
Citralopam 30mg daily
Omeprazole 20mg daily
Simvistatin 80mg Daily
Lopressor 25mg [**Hospital1 **]
Hydralazine 50mg [**Hospital1 **]
Lidoocaine patch 5% daily
Megestrol 40mg [**Hospital1 **]
Mirtazapine 7.5mg QHS
MVI
Senna prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Tramadol 50 mg Tablet Sig: 0.25 Tablet PO Q8H (every 8
hours) as needed for pain.
14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours): PLEASE CHANGE THIS MEDICATION TO ONLY PRN FOR SECRETIONS
STARTING [**2163-4-21**].
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for for increased
secretions: PLEASE CHANGE TO ONLY PRN FOR SECRETIONS STARTING
[**2163-4-21**].
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
18. Cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO QHD (each
hemodialysis) for 4 days: ***TO BE GIVEN 2 MORE TIMES TOTAL - ON
WEDNESDAY ([**4-20**]) AND FRIDAY ([**4-22**]), AFTER HD, THIS WILL COMPLETE
PT'S 8 DAY PNA TREATMENT COURSE.
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol) for 4 days: ***TO BE
GIVEN 2 MORE TIMES TOTAL - ON WEDNESDAY ([**4-20**]) AND FRIDAY ([**4-22**])
AFTER HD, THIS WILL COMPLETE PT'S 8 DAY PNA TREATMENT COURSE.
20. Megestrol 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] of [**Location (un) 55**]
Discharge Diagnosis:
# CHF Exacerbation
# ESRD - HD dependent
# Pneumonia
# Pressure Ulcers (from prior)
# h/o Atrial Fibrillation
# Depression
# mild thrombocyopenia - Please tell your future provider to be
cautious and to closely monitor your platelets when anyone uses
heparin
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1L per day (or less)
<br>
Your diagnosis are as below - you are to resume treatment for
your PNA with antibiotics to be given as prescribed following
your next Wed and Fri HD sessions - will then be completed.
Limit your usual fluid intake as above as with this mild
infection your ability to tolerate extra fluid in your lungs are
even less.
<br>
If your breathing gets worse - if you are having more secretion
problems - get immediate mucomyst neb and albut/ipratrop nebs -
cont/resume your Guaifenesin and scheduled mucomyst nebs for
next 2 days if you have improving sx to initial treatment. If
worsens and developing new fevers/chills - or any other
concerning symptoms - return to the hospital.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2163-4-19**] 2:15
<br>
Please call and arrange a follow-up appointment with PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) 569**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] in [**2-8**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2163-4-19**]
|
[
"585.6",
"V45.81",
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"707.07",
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"428.0",
"707.20",
"707.03",
"486",
"287.5"
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14145, 14218
|
6288, 11464
|
282, 292
|
14520, 14528
|
3989, 6265
|
15399, 15884
|
2788, 2909
|
11872, 14122
|
14239, 14499
|
11490, 11849
|
14552, 15376
|
2924, 3970
|
223, 244
|
320, 2012
|
2034, 2399
|
2415, 2772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,442
| 169,010
|
43212
|
Discharge summary
|
report
|
Admission Date: [**2132-6-23**] Discharge Date: [**2132-6-30**]
Date of Birth: [**2056-8-27**] Sex: M
Service: CSU
CHIEF COMPLAINT: This is a 75-year-old male patient of [**Known firstname **].
[**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] and [**Known firstname **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] referred for an
outpatient cardiac catheterization due to an abnormal stress
echocardiogram.
HISTORY OF PRESENT ILLNESS: In [**2130-11-17**], PTA with stenting,
[**2131-11-23**] diffuse instent restenosis of RSFA stent status post
PTA of entire right SFA and a placement of a new stent. On
[**2132-3-26**] status post left SFA stent placement and right SFA
stent placement. Patient has a history of a silent MI
approximately seven years. For 4-6 weeks prior to admission,
he had been experiencing symptoms of heartburn with activity
and anxiety. A GI workup initially revealed a stomach polyp
and an esophageal polyp, which was biopsied and found
negative. Dobutamine stress echocardiogram on [**2132-6-18**] was
positive for chest pain and EKG changes. Echocardiogram
revealed an EF of 50 percent, posterior basilar akinesis,
aortic sclerosis, no AI, thickened mitral valve, mild MR,
concentric left ventricular hypertrophy, mild-to-moderate TR,
mild pulmonary hypertension, whose exercise imaging revealed
mid to apical and inferior apical marked hypokinesis
consistent with LAD stenosis.
Patient was then referred for cardiac catheterization, which
he underwent on [**2132-6-23**]. The catheterization revealed
normal left main with LAD 80 percent occlusion at the origin,
80 percent mid occlusion, left circumflex occluded after a
large OM-1 with a 70 percent. OM-2 fills by collaterals and
RCA occluded. At that time, the patient was referred for
coronary artery bypass grafting by [**Known firstname **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
PAST MEDICAL HISTORY: GERD.
Silent MI seven years.
Status post prostate cancer treated with radiation treatment.
PVD status post right and left SFA stenting.
Stomach polyp.
ALLERGIES: Latex.
MEDICATIONS AT HOME:
1. Zestril 40 mg q.d.
2. Plavix 70 mg q.d.
3. Aspirin 325 mg q.d.
4. Ranitidine 150 mg b.i.d.
5. Lasix 5 mg q Monday and Thursday.
6. Prilosec 40 mg b.i.d.
7. Folic acid 1.6 mg daily.
8. Multivitamin daily.
9. Flomax 0.4 mg daily.
10. Norvasc 2.5 mg q Monday, Wednesday, and Friday, and
5 mg q Tuesdays, Thursdays, and Saturdays.
11. Lipitor 5 mg daily.
12. Fish oil 1000 mg daily.
13. Lorazepam prn for anxiety.
14. Cranberry capsules 405 mg q.h.s.
PHYSICAL EXAMINATION ON ADMISSION: Heart rate 88, blood
pressure 110/63. General: Alert and oriented times three.
Head is normocephalic, atraumatic. Neck is supple, no
bruits. Chest was clear to auscultation bilaterally.
Cardiac: Regular, rate, and rhythm, normal S1, S2. Abdomen
is soft, nontender, nondistended. Neurologic: Grossly
intact. Pulses: 2 plus bilateral radial, 2 plus left
femoral, and 1 plus right dorsalis pedis.
LABORATORY DATA AT DISCHARGE: WBC 4.9, hematocrit 30.0,
platelets 184, BUN 18, creatinine 1.3.
Chest x-ray from day of discharge pending.
SUMMARY OF HOSPITAL COURSE: The patient was admitted on
[**2132-6-23**] for cardiac catheterization, and was subsequently
referred for coronary artery bypass grafting. He went to the
operating room under the care of [**Known firstname **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2132-6-24**]. He underwent a CABG x5 with a LIMA to the LAD and
saphenous vein grafting to D1, OM, ramus, and PDA. His OR
course was uneventful with a cross-clamp time of 89 minutes
and a bypass time of 106 minutes.
He left the operating room, and was transferred to the
Cardiac Surgery Recovery Unit on Levophed and propofol drips.
He was extubated on the evening of the surgery. He was
transferred to the inpatient floor on postoperative day one.
On postoperative day two, his chest tubes and wires were
D/C'd. He was followed throughout his hospital course by
Physical Therapy and on [**6-29**], was found to have a safe level
for discharge home with use of a cane, and was referred to
outpatient cardiac rehab.
DISCHARGE CONDITION: T max 100, pulse 81 in sinus rhythm,
blood pressure 125/70, respiratory rate 18, on room air
oxygen saturation 100 percent. Neurologic: Awake, alert,
and oriented times three. Cardiac: Regular, rate, and
rhythm. No murmurs, rubs, or gallops. Respiratory: Lungs
sounds are clear bilaterally. GI: Positive bowel sounds.
Abdomen is soft, nontender, nondistended. Incisions:
Sternal incision with staples intact, open to air, and no
drainage. Right lower extremity harvest site with Steri-
Strips intact and open to air.
DISCHARGE STATUS: The patient will be discharged home today,
[**2132-6-30**] in stable condition with visiting nurse to follow.
DISCHARGE DIAGNOSIS: Coronary artery disease status post
coronary artery bypass graft times five.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q.d. for seven days.
2. Potassium chloride 20 mEq p.o. q.d. for seven days.
3. Aspirin 325 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Flomax 0.4 mg q.d.
7. Lopressor 25 mg p.o. b.i.d.
8. Lipitor 5 mg p.o. q.d.
9. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. prn.
FOLLOW-UP PLANS: Follow up with [**Known firstname **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
approximately four weeks and cardiologist, [**Known firstname **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
in [**1-18**] weeks. Follow up [**Known firstname **]. [**Last Name (STitle) 93100**] in [**1-18**] weeks.
Visiting nurses will also follow patient as an outpatient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (Titles) 93101**]
MEDQUIST36
D: [**2132-6-30**] 11:16:09
T: [**2132-6-30**] 11:38:46
Job#: [**Job Number **]
|
[
"443.9",
"412",
"V10.46",
"401.9",
"530.81",
"254.8",
"414.01",
"413.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
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"39.61",
"36.15",
"88.52",
"07.81",
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icd9pcs
|
[
[
[]
]
] |
4299, 4958
|
5081, 5392
|
4980, 5058
|
2179, 2680
|
3270, 4277
|
3131, 3241
|
5410, 6069
|
154, 462
|
491, 1959
|
2695, 3116
|
1982, 2158
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,009
| 161,927
|
48183
|
Discharge summary
|
report
|
Admission Date: [**2176-10-30**] Discharge Date: [**2176-11-18**]
Date of Birth: [**2116-9-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Epistaxis
Major Surgical or Invasive Procedure:
Embolization of right internal maxillary artery
Stenting of right common carotid artery
Open gastric feeding tube placement
Pharyngeal biopsy
PICC placement.
History of Present Illness:
Patient is a 60yo man with history of laryngeal SCC s/p XRT and
total laryngectomy and left modified neck resection, DVT (x2, on
lifelong coumadin) who presents with 2 day history of severe
epistaxis.
.
The patient was in his usual state of health until last night he
began spitting up large amounts of red blood that was in his
mouth/throat. He notes spitting out cupfulls of blood at home.
He initially thought this would pass, but it continued to occur
a total of four times prompting his presentation to the ED.
Patient denied any dizziness/LH or abdominal pain. Of note, he
had pain in his right neck/jaw and aphasia for the past several
months. He was recently admitted to the hospital where work-up
demonstrated esophageal stricture (s/p EGD dilation) and
pharygneal diverticulum. There was no sign of recurrence of his
laryngeal CA. Of note, he had a PET-CT in [**2176-8-16**] which was
concerning for recurrence in the post-laryngectomy bed and
neopharynx and esophagus.
.
In the ED, initial VS were: T- 98.4, HR- 77, BP- 111/66, RR- 20,
SaO2- 99% on RA. The patient triggered twice in ED for large
epistaxis as he was spitting out large amounts of blood. He
also spiked a fever in the ED. While there, ENT scoped the
patient but could not identify a bleeding vessel. Scope
demonstarted post-radiation changes. ENT placed a balloon for
tamponade, however, the patient bled again requiring repacking.
There was also a report of a desaturation to 80% and hypotensive
episode to SBP 80s. He received a dose of vitamin 5 mg, 3 units
of FFP, 5L NS, 1 u pRBC, one dose of vancomycin and morphine for
pain management. He underwent a CTA neck which demonstrated a
"large area in anterior right neck with gas and fluid (possibly
neohypopharynx from laryngectomy?), common carotid appears
involved and has pseudoaneursym 10x9mm from neck of 5mm." He
was taken to the IR suite, where carotid was stented. He was
admitted to the vascular service and then transferred to the
MICU given no plan for surgical intervention.
.
On arrival to the MICU, vital signs were T- 99.2, HR- 72, BP-
122/63, RR- 20, SaO2- 97% on 35% O2. Patient denied any new
bleeding, shortness of breath, chest pain, fevers or chills.
Past Medical History:
Long history of vocal cord dysplasia first identified in [**2157**].
Between [**2157**] and [**2160**] he had multiple episodes of carcinoma in
situ of the larynx that required striping. In [**2160**] he was
diagnosed with microinvasive squamous cell carcinoma of the
right true cord, stage I. He was treated with definitive
radiation therapy between [**11/2160**] and [**1-/2161**] by Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 31966**] at [**Hospital1 2025**]. He did well until [**6-/2171**] when he developed
stridor. An exam under anesthesia on [**2171-7-15**] revealed diffuse
edema of the supraglottic larynx with fullness of the vocal
cord. Biopsies revealed squamous cell carcinoma. He was
considered to have stage III, T3, N0 disease, likely of second
primary origin. In [**10/2171**] he underwent total laryngectomy and
left modified neck dissection. A sternocleidomastoid rotation
flap was used to cover the mediastinal vessels by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1837**]. Pathology revealed no evidence for regional nodal
disease. However, the laryngectomy specimen contained a 3.5cm
moderately differentiated squamous cell carcinoma involving the
bilaterl true cords and extending into the subglottis. The tumor
invaded through the thyroid and tracheal cartilages and into the
surrounding soft tissues and skeletal muscles. Soft tissue
resections were negative for tumor, however the tumor was
present 1mm from the anterior and left posterior soft tissue
margins. The epiglottic and aryepiglottic proximal margins were
negative for tumor. The distal tracheal margin was negative.
There was no evidence for angiolymphatic invasion, but peroreal
invasion was observed. Pathology report considered the patient
to have T4b, stage IV squamous cell cancer of the supraglottic
larynx. Surveillance CT of the neck on [**2172-5-23**] revealed a new
left neck mass and a fine needle aspiration revealed squamous
cell carcinoma which was resected.
.
PAST MEDICAL HISTORY:
- HTN
- Atrial fibrillation
- Mitral valve prolapse
- GERD
- Hypothyroidism
- BPH
- SLE
- H/o DVT in bilateral legs [**2162**] with recurrence, on lifelong
anticoagulation
Social History:
Former smoker, none currently. Denies recreational drugs. Lives
with wife at home.
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 99.8 149/71 64 17 97% on 35%TM
GENERAL - 60 y/o M in NAD
HEENT - Nasal packing in place, lateral neck swelling, trach
site with minimal amount of purrulent drainage, oral thrush
noted
NECK - supple
LUNGS - rhonchorous breath sounds throughout anteriorly
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (DPs)
SKIN - no rashes or lesions
NEURO - awake, non-focal
.
DISCHARGE PHYSICAL EXAM:
VS - T 97.8 BP 112/64 P 55 R 18 S 99%RA
GENERAL - elderly African American man w/ covered trach and
trach mask in no discomfort.
HEENT - PERRL, EOMI
NECK - supple, L graft normal. R neck normal very mildly tender
to palpation, tract lateral of trach draining clear/whitish
fluid (unchaged). Sputum from tracheostomy only when patient
coughs (unchanged).
LUNGS - clear to auscultation bilaterally
HEART - RRR, nl s1, s2, no m/r/g
ABDOMEN - LUQ tube with clean bandage. Appropriately tender to
palpation and improving. No obvious bleeding or erythema. Abd in
general soft, non-tender aside from G tube site, NABS.
EXTREMITIES - no edema bilaterally. 2+ pulses bilateral radial
and dp.
NEURO - A&O x 3, appropriately alert and interactive, moving all
limbs independently
Pertinent Results:
ADMISSION LABS
[**2176-10-30**] 11:55AM BLOOD WBC-9.2 RBC-4.04* Hgb-11.9* Hct-36.6*
MCV-91 MCH-29.4 MCHC-32.5 RDW-13.8 Plt Ct-317
[**2176-10-30**] 11:55AM BLOOD Neuts-85.5* Lymphs-9.3* Monos-4.3 Eos-0.6
Baso-0.3
[**2176-10-30**] 11:55AM BLOOD PT-32.2* PTT-31.2 INR(PT)-3.2*
[**2176-10-30**] 11:55AM BLOOD Glucose-116* UreaN-23* Creat-1.2 Na-140
K-3.7 Cl-103 HCO3-27 AnGap-14
[**2176-10-31**] 03:26AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.5*
.
PERTINENT STUDIES
[**2176-10-30**] CTA Neck - IMPRESSION: 1. A new pseudoaneurysm arising
from the right common carotid artery anteriorly just before its
bifurcation. 2. Soft tissue surrounding the pseudoaneurysm with
multiple foci of gas within. This has increased since the prior
study. The foci of gas extend just below the level of the skin.
This is likely infective in etiology. 3. Soft tissue surrounding
the distal right common carotid artery causing its narrowing.
This likely represents postoperative fibrosis. 4. Thrombosis of
bilateral internal jugular veins. 4. Postoperative changes in
the form of total laryngectomy, left modified neck
dissection,reconstruction flap and tracheostomy.
[**2176-11-9**] CT neck w/ contrast - prelim read - 1. Interval
stenting of right common carotid aneurysm with interval decrease
in pseudoaneurysm. A small focus of hyperdensity (2:101) with
attenuation of the blood pool at the level of the prior
pseudoaneurysm may indicate small residual aneurysm without
connection seen to CCA. 2. Fistulization from oropharynx to the
anterior neck skin surface (2:97-2:125). No adjacent drainable
fluid collection. Resolution of soft tissue gas. 3. New surgical
clip deep to the right zygomatic arch may represent maxillary
artery embolization for epistaxis if there is history of this
(unable to find record of this in OMR). If no history of this,
the etiology of this clip is unclear. 4. Sinus disease in the
maxillary sinuses worse than on [**2176-10-30**]. 5. Post surgical
changes in the neck from total laryngectomy, left modified neck
dissection,reconstruction flap and tracheostomy.
MICRO:
[**2176-10-30**] Blood Culture, Routine-FINAL {PROPIONIBACTERIUM
ACNES}; Anaerobic Bottle Gram Stain-FINAL
[**2176-11-3**] Sputum - STAPH AUREUS (MSSA)
[**2176-11-3**] fistula swab culture - mixed bacterial types
[**2176-11-7**] intra-operative fistula swab - mixed bacterial types
Pathology:
[**2176-11-7**] phayngeal biopsies - Squamous mucosa with chronic
inflammation, stromal sclerosis, and focal basilar atypia, most
likely reactive. Note: Stromal sclerosis consistent with
previous radiation. Multiple levels are examined.
Brief Hospital Course:
60 year old man with a h/o laryngeal SCC s/p XRT, total
laryngectomy, and left modified neck resection, as well as DVTs
x2 on coumadin presenting with severe epistaxis, concerning for
recurrence of SCC.
.
# Epistaxis/orapharyngeal bleeding:
Likely secondary to known laryngeal SCC versus radiation
fibrosis. Patient remained hemodynamically stable in the
setting of his blood loss. ENT was consulted, who helped
initially pack the nares. His warfarin was held and he was
given FFP and vitamin K upon admission. He underwent coiling of
his internal maxillary artery by vascular surgery. Following
the resolution of his bleeding, he was restarted on a heparin
drip for reversible anticoagulation in case he were to
experience additional bleeding. Once enteral access was
obtained and the patient no longer was actively bleeding, his
warfarin was restarted.
# Pharyngeal/carotid/cutaneous fistula:
Patient was found to have a fistula between the pharynx and skin
eroding near the carotid artery, that itself had a
pseudoaneurysm. Dr. [**Last Name (STitle) 1837**] from ENT evaluated the
patient and felt that this is not repairable at this time. He
also had a family meeting during which it was explained how
surgery was unlikely to help at this time given past neck XRT
and poor wound healing. A stent was placed in the right carotid
pseudoaneurysm.
Given the fistula and its proximity to the carotid, oral feeds
were felt to be too dangerous and the patient underwent open G
tube placement on [**2176-11-7**] without complication. His tube feeds
were started, however a few days later he began to note
increased secretions from his trach site, which appeared to be
similar to the tube feed formula in color and consistency. The
formulation of his TF was changed and he was tolerating his full
strength TF upon discharge.
# Trach Site / fistula infection / History of SCC:
Pt initially had significant swelling around trach site and
purulent drainage, which was concerning for soft tissue/fistula
infection. He was evaluated by plastic surgery who felt that
prior to any surgical intervention, the patient required
confirmation that his SCC did not recur. A biospy was obtained
from the neohypopharynx, the results of which were negative;
revealing chronic inflammation, stromal sclerosis, and focal
basilar atypia, most likely reactive and consistent with prior
radiation. As per ENT, the patient will also require an out
patient PET scan to evaluate for any other evidence of
malignancy.
A culture from the region grew MSSA and was notably negative for
MRSA or pseudomonas. As per ID, he was treated initially with
vanc/zosyn, followed by zosyn alone for a total of a 14 day
course. He was to be transitioned to augmentin 875 mg po BID
with long term follow up with ID.
# ?Pneumonia:
Pt had a chronic cough w/ unchanged CXR. However, as sputum
culture grew MSSA the patient was treated with antibiotics as
above.
# History of 2 x DVT:
Patient was on warfarin as an outpatient, and as above, the
patient was given FFP and vitamin K for reversal of his
anticoagulation in the setting of active bleeding. He was then
anticoagulated with a heparin gtt until his bleeding had
stabilized and enteral access was obtained. After which, he was
then bridged to back to warfarin.
.
# A-fib:
The patients home medications (amio and dilt) were held given
the lack of enteral access. He HR remained stable in sinus with
a rate of 70-80s during the admission. He was given metoprolol
IV during his stay for rate control. In the days prior to
discharge, the patients heart rate ranged from 55-70, and he
often did not receive metoprolol. He was in sinus rhythm and
normotensive.
Prior to and upon discharge, he was continued on amiodarone,
however diltizem was not restarted. He should follow up with
his PCP in order to appropriately control his atrial
fibrillation and hypertension (see below).
.
# HTN:
The patient's home antihypertensive medications were adjusted to
metorpolol IV as he was unable to take po medications. Given
his average-low heart rate (generally 60-70s in the days leading
to discharge, he often did not receive this medication for
multiple days prior to his discharge.
Upon discussion with pharmacy, his antihypertensive medications
were adjusted to amiodarone only for easier administration via
the G tube. Should he require diltiazem going forward, it would
have to be transitioned to the immediate release formulation in
order to be crushed and admininstered via the G tube four times
daily.
.
# Hyperthyroidism:
The patient was continued on his home levothyroxine which was
converted to IV while he was unable to take oral medications.
He was discharged home on po levothyroixine with instructions
that this can not be taken within one hour of his tube feedings.
==========================================================
TRANSITIONAL ISSUES:
==========================================================
-Pt will need close ENT follow-up for his fistula involving R
carotid as well as the possibility that his cancer has returned.
Path from the biospy during this hospitalization was negative
for recurrence. Patient will most likely require an outpatient
PET scan, however this could not be scheduled as an inpatient.
-Poor overall prognosis, Pt may benefit from additional
palliation and/or goals of care discussions. His code status
was changed to DNR/DNI during this hospialization.
-Patient has poor nutritional status due to difficulties with
the initiation of tube feeds.
-Patient will require long term antibiotics to be dictated by
the infectious disease team who are following his case.
Medications on Admission:
1. Levoxyl 150 mcg Tablet [**Date Range **]: One (1) Tablet PO once a day.
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Date Range **]: One (1)
Capsule, Ext Release 24 hr PO once a day.
3. omeprazole 20 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. amiodarone 200 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
5. diltiazem HCl 180 mg Capsule, Extended Release [**Date Range **]: One (1)
Capsule, Extended Release PO once a day.
6. duloxetine 60 mg Capsule, Delayed Release(E.C.) [**Date Range **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Combivent Inhalation
8. Lovenox 120 mg/0.8 mL Syringe [**Date Range **]: One (1) injection
Subcutaneous once a day.
Disp:*7 syringes* Refills:*0*
Discharge Medications:
1. Tube Feeds
Peptamen 1.5 Full strength; 360 cc per feeding: 4 feedings/day:
Hold feeding for residual >= : 200 ml; please check before each
feeding.
Flush w/200 ml water before & after each feeding
8 cases/month; 2250 calories/day
2. warfarin 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Levoxyl 150 mcg Tablet [**Date Range **]: One (1) Tablet PO once a day:
Please do not give within 1 hour of tube feeds.
Disp:*30 Tablet(s)* Refills:*2*
4. prazosin 1 mg Capsule [**Date Range **]: One (1) Capsule PO QHS (once a day
(at bedtime)): Please open capsule and put into water, then
administer through feeding tube.
Disp:*30 Capsule(s)* Refills:*2*
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): Please dissolve in
10 cc of water and administer via feeding tube.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
Ok to crush and administer via feeding tube.
Disp:*30 Tablet(s)* Refills:*2*
7. Semi electric hospital bed
Semi electric hospital bed
8. [**Last Name (un) **] Compressor
[**Last Name (un) **] Compressor
Use daily as directed x1 year
9. Suction machine
Suction machine
Use daily as needed x1 year
[**75**]. Suction supplies
Suction supplies
Daily use as needed x1 year
[**76**]. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Year (2 digits) **]: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Open capsule
and dissolve in water. Administer via feeding tube.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. amoxicillin-pot clavulanate 875-125 mg Tablet [**Year (2 digits) **]: One (1)
Tablet PO Q12H (every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
13. metoclopramide 10 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
14. Combivent 18-103 mcg/Actuation Aerosol Inhalation
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Neo-pharynx to right carotid to skin fistulous tract
Right carotid pseudoaneurysm s/p stent
MSSA pneumonia
Fistula polymicrobial infection
.
Secondary:
Atrial fibrillation
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 101565**],
It was a pleasure taking part in your care. We hope you
continue to feel better. You came to the hospital because you
had bleeding from your nose. You were seen by our ENT (ear,
nose, and throat) specialists, general surgeons, neurovascular
specialists, and infectious disease specialists.
We found that you had a fistula, or internal connection, between
your throat through to your neck, near your carotid artery, and
the skin. It is unclear what caused this, but given your prior
squamous cell cancer, that is a possibility. It may also have
been worsened by active infection and your previous radiation
treatment. You received blood transfusions and our ENT
specialists were able to stop the bleeding from your nose. Your
blood counts remained stable afterwards.
Our neurovascular specialists put a metallic stent in your right
carotid artery because you had pseudoaneurysm, or a buldge, of
this very important artery. This has remained stable on repeat
imaging of your neck.
Due of the proximity of your fistula to your carotid artery, our
ENT specialists felt that you could not be safely allowed to eat
or drink anything by mouth. You therefore had a feeding tube
placed in your stomach by our general surgeons. Our ENT
specialists also took additional biopsies of your pharynx in
order to determine whether or not your squamous cell cancer has
returned, the results of which were negative. They felt that
there are currently limited options for the reconstruction of
the tissues of your neck given the possibility that cancer or an
active infection may be present, as well as your history of
radiation to the area. You had several bacteria growing from
cultures from your fistula and a bacteria called MSSA growing
from your sputum. You were seen by our infectious disease
experts who recommended specific antibiotics.
You were placed on IV blood thinners during your stay in the
hospital because of your past history of leg and lung blood
clots. You tolerated the placement of your feeding tube well and
were able to tolerate tube feeds by the time of discharge.
We made some changes to your medications to accommodate your
feeding tube:
START:
-Prazosin daily (this replaces tamsulosin)
-Lansoprazole daily (this replaces omeprazole)
-Warfarin 5 mg daily unless otherwise directed
-Augmentin daily to control infection
-metoclopramide 4x daily to help digest tube feeds
STOP:
-Tamsulosin
-Omeprazole
-Diltiazem
-Lovenox
You have several follow-up appointments with your primary care
physician as well as specialists in ENT, general surgery, and
infectious diseases.
Followup Instructions:
Name:[**Doctor First Name 11004**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 101566**] [**Name8 (MD) 101567**],MD
Specialty:Primary Care
Location: [**Location (un) 2274**]-[**Hospital1 **]
Address: [**Hospital1 34796**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 68159**]
Appointment: MONDAY, [**11-25**] at 9:50am
**Please speak with your PCP about the need to be referred to a
General Surgeon within 1-2 weeks of your discharge from the
hospital.**
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: FRIDAY [**2176-11-22**] at 3:50 PM
With: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2176-12-3**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
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29,120
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3176
|
Discharge summary
|
report
|
Admission Date: [**2145-6-10**] Discharge Date: [**2145-6-22**]
Service: CARDIOTHORACIC
Allergies:
Ultram / Darvocet-N 50 / Red Dye
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2145-6-16**] Two Vessel Coronary Artery Bypass Grafting(left internal
mammary to left anterior descending and vein graft to diagonal).
[**2145-6-10**] Cardiac Catheterization
History of Present Illness:
Mrs. [**Known lastname 14800**] is an 83 year old female with no prior history of
coronary disease who presented to ED with suddent onset of chest
pain. On the day of admission, she was in USOH when she had
breakfast, then ambulated to bathroom, was having a normal BM
and developed sharp chest pain under right breast, non
radiating, associated with diaphoresis and nausea but no
vomiting. Patient waited for some time, then called EMS. Patient
given ASA with some relief of pain then sl ntg in ED with total
pain relief. She denies ever having similar symtpoms. She had a
stress test done several years ago in the setting of knee
surgery and chest pain at that time that was negative. Her
effort tolerance was excellent and she does stairs several times
per day without symtpoms. She only endorses fatigue the day
prior to presentation. Otherwise no fever, chills, GI or GU
complaints. In the ED, VS 97.6 63 135/65 16 94% RA. Patient was
CP free and resolving ST elevations on EKG. EMS strips showing
ST elevations ~1mm in V1-V3 when patient having pain then with
deep TWI in V1-3. First set of cardiac enzymes revealed a CK of
40 and a Troponin of 0.07. Patient received ASA 325, Plavix
load, a heparin drip was started and the patient was sent
urgently to the cath lab.
Past Medical History:
1. History of melanoma (stage IIB) right upper back, [**7-24**], no
evidence of recurrence, followed by Dr. [**Doctor Last Name 14949**] oncology.
2. History of colon cancer diagnosed in [**2134**], status post
resection, six months of chemotherapy, last colonoscopy [**1-25**], no
evidence of recurrence.
3. Chronic sinusitis. Followed by Dr. [**Last Name (STitle) **]. History of
sinus surgery in [**2141**]. Currently on Levaquin. Reports that she
"alternates" between Levaquin and Augmentin. Has persistent
nocturnal cough, history of bronchiectasis.
4. Bipolar disorder. Maintained on lithium 300 mg daily.
Excellent functioning, no side effects.
5. History of basal cell carcinoma
6. Lymphadenitis-two years old.
7. Right Leg Vein ligation [**2135**]
8. Cholecystectomy-[**2141**]
9. Bilateral TKR-[**2139**]
10. Melanoma resection [**2141**]
11. Sinus surgery-[**2141**]
Social History:
Patient denies any Tobacco use. Only rare EtOH. Widowed, lives
with daughter (recent move), fully independent. Retired State
employee. Five children many grandchildren.
Family History:
Daughter with DCIS. Brothers with MI, stomach cancer, liver
cancer. Mother and brother with diabetes. There is no family
history of premature coronary artery disease or sudden death.
Physical Exam:
VS: Afebrile, BP 170/78 HR 56 RR 15 O2
Gen: lying flat s/p cath, pleasant, appropriate, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, obese, NTND. No HSM or tenderness.
Ext: Trace edema b/l, dry, good distal pulses
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Neuro: nonfocal
Discharge
General NAD Vitals 97.9, 132/80, 88 SR, 18, 95% RA Sat, 85.5 kg
Neuro alert/oriented x3, right pronator drift, EOMI, PERRLA,
mild expressive and receptive aphasia with mod cognitive
deficits
Card RRR no m/r/g
Resp CTA bilat decreased bilat bases no wheezes/rhonchi
Abd soft, NT, ND obese
Ext warm pulses palpable +1 edema LE
Inc Sternal with steris, no erythema/drainage sternum stable
Inc Left endovascular harvest steris no erythema no drainage
Pertinent Results:
[**2145-6-22**] 07:05AM BLOOD WBC-12.8* RBC-3.69* Hgb-11.9* Hct-33.8*
MCV-92 MCH-32.4* MCHC-35.3* RDW-14.3 Plt Ct-298
[**2145-6-17**] 02:50AM BLOOD WBC-17.3* RBC-3.74* Hgb-12.2 Hct-34.1*
MCV-91 MCH-32.7* MCHC-35.8* RDW-14.9 Plt Ct-166
[**2145-6-10**] 10:55AM BLOOD WBC-9.1 RBC-4.18* Hgb-13.5 Hct-40.0
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.2 Plt Ct-249
[**2145-6-10**] 04:00PM BLOOD Neuts-74.8* Lymphs-21.1 Monos-3.4 Eos-0.5
Baso-0.2
[**2145-6-10**] 10:55AM BLOOD Plt Ct-249
[**2145-6-16**] 12:31PM BLOOD Fibrino-206
[**2145-6-10**] 11:13AM BLOOD D-Dimer-514*
[**2145-6-10**] 04:00PM BLOOD Ret Aut-1.3
[**2145-6-22**] 07:05AM BLOOD Glucose-119* UreaN-22* Creat-1.1 Na-139
K-4.8 Cl-105 HCO3-25 AnGap-14
[**2145-6-10**] 10:55AM BLOOD Glucose-144* UreaN-21* Creat-1.0 Na-143
K-4.4 Cl-108 HCO3-28 AnGap-11
[**2145-6-19**] 03:40PM BLOOD ALT-41* AST-32 LD(LDH)-267* AlkPhos-59
Amylase-72 TotBili-0.3
[**2145-6-10**] 04:00PM BLOOD ALT-14 AST-16 CK(CPK)-75 AlkPhos-49
Amylase-85 TotBili-0.4 DirBili-0.1 IndBili-0.3
[**2145-6-19**] 03:40PM BLOOD Lipase-95*
[**2145-6-11**] 11:35AM BLOOD Lipase-43
[**2145-6-14**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2145-6-10**] 04:00PM BLOOD CK-MB-NotDone cTropnT-0.54*
[**2145-6-20**] 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.3
[**2145-6-18**] 08:05AM BLOOD Albumin-2.7* Mg-2.1
[**2145-6-10**] 04:00PM BLOOD VitB12-790
[**2145-6-11**] 03:45AM BLOOD %HbA1c-5.7
[**2145-6-19**] 11:10AM BLOOD Triglyc-112 HDL-48 CHOL/HD-2.4 LDLcalc-47
[**2145-6-19**] 11:10AM BLOOD Lithium-0.3*
Date: [**2145-6-21**]
Signed by [**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) 2621**], CCC-SLP on [**2145-6-21**] Affiliation:
[**Hospital1 18**]
SPEECH, LANGUAGE and COGNITIVE EVALUATION
HISTORY:
Thank you for consulting on this 83 y/o female admitted [**2145-6-10**]
for right sided chest pain . Cardiac cath revealed 2V disease,
now s/p CABG on [**2145-6-16**]. A Code stroke was called on [**2145-6-19**] for
right arm weakness and decreased speech output. MRI revealed
left
MCA parietal infarct.
PMH includes colon CA s/p resection, sinusitis, bipolar d/o,
melanoma right back s/p resection, CCY, bilateral TKR, sinus
surgery '[**41**]
The pt has been tolerating POs well without signs of aspiration.
We were consulted for a speech and language evaluation. An
informal assessment was completed at the bedside.
Per discussion with the pt and her daughters, the pt was living
with her daughter prior to admission, but was almost fully
independent, managing her finances, doing laundry, shopping /
cooking ect. Her daughters report a significant decline from
baseline, but did admit to improvement from yesterday.
VERBAL EXPRESSION:
Verbal expression was fluent with normal phrase length. Speech
was 100% intelligible however noted to have intermittent mild
dysarthria. She presented with a mild to moderate anomia that
was
more obvious in confrontation tasks than in conversational
speech. several phonemic paraphasias were also observed in
conversational speech. She was able to produce automatics, but
could not recall all biographical information (particularly
phone
numbers and area code). There was also evidence of perseveration
that the pt was not aware of. Repetition was in tact for
sentence
level information.
AUDITORY COMPREHENSION:
Auditory comprehension was adequate for one step commands, but
she was only ~50% accurate with 2 and 3 step commands. she
spontaneously utilized auditory rehearsal and was able to recall
the correct information, but could not perform all steps of the
command. She was aware of her speech errors ~50% of the time and
made efforts to correct her errors. There was also evidence of
difficulty retaining information in lengthier segments and had
difficulty recalling details from paragraph level information.
[**Location (un) **]:
Not formally assessed.
WRITING:
The pt was able to write her name and part of her address, but
had difficulty with numbers and frequently said one number and
wrote another. Her insight was limited in this area.
COGNITION:
The pt presented with moderate cognitive deficits with limited
insight into her deficits. Her verbal expression was not
organized when asked to tell a narrative story and her ideas
were
out of sequence with limited regard for the listener's
background
information. She attempted the clock drawing, but did not
initially draw any numbers or hands. She had difficulty [**Location (un) 1131**]
the time off of a clock, but was able to self correct on the
third attempt.
SUMMARY:
Ms. [**Known lastname 14800**] presented with a mild expressive and receptive
aphasia
with moderate cognitive deficits. She is currently able to
express all basic needs and can participate in conversational
level speech, but does have word finding difficulties,
occasional
perseveration and paraphasic errors. Auditory comprehension
breaks down at the 2 step level and she has difficulty recalling
information from lengthier strings of information. She also has
more significant cognitive deficits with impairments planning,
organizing and sequencing. Per discussion with her family, she
is
well below baseline and would benefit from intense
speech-therapy
services 5-7 days per week to maximize recovery to a more
independent level.
RECOMMENDATIONS:
1. Suggest intense speech-language therapy for
cognitive-linguistic deficits 5-7 days / week.
2. provide information in small pieces and ask the pt to state
back the information to ensure understanding of important
information.
_________________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MS, CCC-SLP
Pager#[**Serial Number 2622**]
Face Time: 1:30-2:30
Total Time: 90 minutes
RADIOLOGY Final Report
CHEST (PA & LAT) [**2145-6-19**] 9:33 AM
CHEST (PA & LAT)
Reason: evaluate pneumo
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
evaluate pneumo
STUDY: PA and lateral chest, [**2145-6-19**].
HISTORY: 83-year-old woman status post CABG. Evaluate for
pneumothorax.
FINDINGS: Comparison is made to previous study from [**2145-6-18**].
The tiny left apical pneumothorax is not well seen on today's
study, likely resolved. Bibasilar subsegmental atelectasis is
again present. There is cardiomegaly. There are no signs of
overt pulmonary edema. Small pleural effusions are present.
There are median sternotomy wires.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2145-6-19**] 3:52 PM
RADIOLOGY Preliminary Report
CTA HEAD W&W/O C & RECONS [**2145-6-19**] 9:18 AM
CTA HEAD W&W/O C & RECONS
Reason: eval for cva; please do non-contrast as well as cta to
look
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with recent CABG developed sudden focal
neurological deficits - right hand weakness and coordination
REASON FOR THIS EXAMINATION:
eval for cva; please do non-contrast as well as cta to look for
occlusion
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: CT of the head.
CLINICAL INFORMATION: Patient with right hand coordination
deficit and weakness, for further evaluation.
TECHNIQUE: Axial images of the head were obtained without
contrast. Following this, using departmental protocol, CTA of
the head was acquired.
PRIOR EXAMINATIONS: Correlation was made with the previous head
CT examination of [**2144-5-29**].
FINDINGS: There is periventricular hypodensity seen due to small
vessel disease. There is no midline shift, mass effect,
hydrocephalus, or acute hemorrhage identified. There is no
evidence of loss of [**Doctor Last Name 352**]-white matter differentiation.
The CTA examination demonstrates normal vascular structures in
and around the circle of [**Location (un) 431**]. The distal carotid and
vertebral arteries demonstrate normal flow without evidence of
stenosis or occlusion. No evidence of an aneurysm greater than 3
mm in size is seen.
IMPRESSION: No acute intracranial abnormalities on head CT
without contrast. No evidence of vascular occlusion or stenosis
on the CTA of the head. No vascular filling defects are
identified.
COMMENT: This report will be finalized following availability of
reformatted images and 3D images.
DR. [**First Name (STitle) 2618**] [**Doctor Last Name **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
RADIOLOGY Final Report
MR HEAD W/O CONTRAST [**2145-6-19**] 9:42 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: recommended by neurology / please assess for stroke
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with
REASON FOR THIS EXAMINATION:
recommended by neurology / please assess for stroke
Examination: Sagittal short TR, short TE, spin echo imaging was
performed along with axial [**Last Name (LF) 14950**], [**First Name3 (LF) **] TR, long TE fast spin
echo, gradient echo, and diffusion imaging. Three dimensional
time of flight MRA was performed. After administration of
gadolinium intravenous contrast, axial short TR, short TE spin
echo imaging was performed.
Comparison: head CT and CTA of [**2145-6-19**].
There is an acute left middle cerebral artery branch infarction
in the anterior parietal lobe. There is no evidence of
hemorrhage. There is partial opacification of the mastoid air
cells bilaterally, as well as extensive opacification of the
paranasal sinuses. The paranasal sinus disease appears unchanged
since the recent head CT scan.
The MR demonstrates no vascular abnormalities.
Conclusion: Left middle cerebral artery anterior parietal
infarction. No evidence of hemorrhage. No vascular abnormalities
detected.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: SUN [**2145-6-20**] 12:13 PM
Cardiology Report ECG Study Date of [**2145-6-16**] 3:16:44 PM
Sinus rhythm, rate 65. Since tracing of [**2145-6-15**] minimal axis
shift to the
right has occurred. No other changes are seen.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 1730**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 [**Telephone/Fax (3) 14951**]/433 36 54 49
Cardiology Report ECHO Study Date of [**2145-6-16**]
PATIENT/TEST INFORMATION:
Indication: Intraop CABG. Evaluate Aortic Atheroma,
biventricular function, valve function
Height: (in) 63
Weight (lb): 190
BSA (m2): 1.89 m2
BP (mm Hg): 130/65
HR (bpm): 58
Status: Inpatient
Date/Time: [**2145-6-16**] at 11:42
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.6 cm (nl <= 5.2 cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.5 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.29 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%)
Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aorta - Arch: 2.6 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.2 cm (nl <= 2.5 cm)
Aortic Valve - Valve Area: *2.1 cm2 (nl >= 3.0 cm2)
Mitral Valve - Peak Velocity: 0.7 m/sec
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.00
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV
systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending
aorta. Normal aortic arch diameter. Simple atheroma in aortic
arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic
(normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications.
Conclusions:
Pre Bypass: The left atrium is mildly dilated. No mass/thrombus
is seen in the
left atrium or left atrial appendage. A patent foramen ovale is
present. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity
size is normal. There is mild regional left ventricular systolic
dysfunction
with moderate apical anterior and anteroseptal hypokinesis.
There is normal
systolic function of the remaining segments. Overall left
ventricular systolic
function is mildly depressed. Right ventricular chamber size and
free wall
motion are normal. There are simple atheroma in the aortic arch.
There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no
pericardial effusion.
Post Bypass: Preserved biventricular function. LVEF 50% There is
still some
mild hypokinesis of the distal/apical portion of the anterior
and anteroseptal
walls. Right ventricular function is normal. Mitral
regurgitation is unchanged
and mild. Aortic contours are intact. Remaining exam is
unchanged. All
findings discussed with surgeons at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2145-6-21**] 22:12.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mrs. [**Known lastname 14800**] was admitted and ruled in for an acute myocardial
infarction. Cardiac catheterization was significant for a severe
90% ostial lesion in left anterior descending artery along with
a 70% stenosis in the diagonal branch(see result section for
additional detail). Given her critical coronary anatomy, urgent
revascularization surgery was planned. However surgery was
delayed secondary to development of abdominal pain. Given
concern for possible ischemic bowel via embolization during
cardiac catheterization, an abdominal CT scan was obtained. CT
scan was essentially negative for any intra-abdominal pathology.
Given her stable cardiac status and a recent Plavix load prior
to catheterization, it was decided to delay surgery for several
more days and perform additional workup. Vein mapping revealed
suitable saphenous vein in her left leg. Carotid ultrasound
showed no significant disease on the internal carotid arteries.
Transthoracic echocardiogram revealed an LVEF of 40% with 1-2+
mitral regurgitation. Her preoperative course was otherwise
uneventful. She remained pain free on intravenous Heparin and
her abdominal pain gradually improved.
On [**6-16**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting. For surgical details, please see seperate dictated
operative note. Following the operation, she was brought to the
CSRU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated. She experienced postop
atrial fibrillation which successfully converted back to sinus
rhythm after Amiodarone. Low dose beta blockade and diuretics
were initiated. She was transferred to the floor on POD #1 and
was doing well until POD#3 when she developed R hand weakness
and slurred speech. She had a head CTA which was negative for a
bleed or infarct and then had an MRI which revealed a R parietal
infarct. Her symptoms improved over the next 48 hours and
neurology recommended ASA and statins. She was evaluated by PT,
OT and speech therapy. She was ready and discharged to rehab in
stable condition on POD# 6.
Medications on Admission:
Flonase, Lithium, MVI, Calcium
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lithium Carbonate 300 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 7
days.
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 3 days.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Coronary artery disease - s/p CABG
Left middle cerebral artery anterior parietal infarction
Postop Atrial Fibrillation
Hypertension
Obesity
History of Colon Cancer
Bipolar Disorder
Right Leg Vein Ligation
Bilateral Total Knee Replacements
Discharge Condition:
Good
Discharge Instructions:
Patient should shower daily, no baths.
No creams, lotions or ointments to incisions.
No driving for at least one month.
No lifting more than 10 lbs for at least 10 weeks from the date
of surgery.
Monitor wounds for signs of infection. Please call cardiac
surgeon if start to experience fevers, sternal drainage and/or
wound erythema. [**Telephone/Fax (1) 170**]
Followup Instructions:
Make an appointment with each of the following:
Cardiac surgeon, Dr. [**Last Name (STitle) 914**] in [**3-25**] weeks [**Telephone/Fax (1) 170**]
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 4775**]
Cardiologist: Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**0-0-**] in [**1-23**] weeks
Neurologist: Dr [**Last Name (STitle) **] [**Name (STitle) **] [**0-0-**] [**2145-7-12**] at 2pm [**Location (un) 14952**] [**Location (un) **], MA
Completed by:[**2145-6-22**]
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"V10.05",
"427.31",
"V10.82",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"88.53",
"88.56",
"37.22",
"36.15",
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icd9pcs
|
[
[
[]
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|
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|
22061, 22068
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,866
| 155,490
|
48701
|
Discharge summary
|
report
|
Admission Date: [**2135-5-28**] Discharge Date: [**2135-6-14**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hemodialysis line not working
Major Surgical or Invasive Procedure:
Balloon angioplasty and tunneled catheter placement
Peritoneal dialysis catheter placement
History of Present Illness:
50 year old man with history of end stage renal disease
secondary to amyloidosis, paroxysmal atrial fibrillation, type 2
diabetes on insulin admitted after his hemodialysis line was
found to be not working halfway through his hemodialysis session
today. Because of his history of hyperkalemia, it was not felt
to be safe to return him to his nursing home without access. He
has been admitted to the hospital for monitoring and for
resolution of his access problem.
In the ED, his vital signs were: 97.9 92 110/60 18 98%
RA. He had no complaints. He was seen by nephrology, who left
recommendations in the chart and asked that he not be given any
prophylactic heparin given his history of bleeding.
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-5**] now on
hemodialysis (right groin line)
inferior vena cava stent
Sarcoidosis
Pulmonary aspergillosis - on chronic voriconazole
Type 2 Diabetes, on insulin
Chronic Hepatitis C
Hypertension
Sinusitis
Paroxysmal atrial fibrillation,
Clostridium difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity deep vein thrombosis ([**2132**])
Pancreatitis
Bilateral below the knee amputation
Right index and fifth finger amputations
Allerties:
Enalapril--pancreatitis
Codeine--lightheadedness
Primary Care Physician: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **]
Social History:
Smoked 1 pack per day X 30 years but quit 3 months ago. +
history of alcohol abuse, but stopped 4 years ago. Previous drug
use with cocaine (+IV drug use), has been clean since about
[**2127**]. Girlfriend [**Last Name (un) 102399**] is involved in his care. Lives in a
care home in [**Location (un) 669**]. Mother lives nearby.
Family History:
Mother, brother with diabetes. No h/o kidney disease
Physical Exam:
(on admission per Dr. [**Last Name (STitle) **]
98.0 93/61 104 24
Pleasant, frail man in NAD. Breathing comfortably.
EOMI, slight redness to his right corneal membrane. OP clear,
MM dry.
Neck supple.
S1, S2, RRR (not tachy to my exam), systolic murmur at LUSB and
at apex.
Lungs clear b/l but with poor air movement throughout.
Abd soft, NT, ND. +BS
Right femoral catheter clean, dry, no erythema or induration.
b/l BKA well healed, skin somewhat dry. No edema.
Missing digits of his hands.
Pleasant, answers questions appropriately but does not have
impressive knowledge of his medications or medical history.
Pertinent Results:
[**2135-5-28**] 03:40PM BLOOD WBC-8.6 RBC-5.09# Hgb-14.9# Hct-48.9#
MCV-96 MCH-29.3 MCHC-30.4* RDW-17.3* Plt Ct-438#
[**2135-5-29**] 08:15AM BLOOD WBC-12.8* RBC-4.77 Hgb-14.0 Hct-45.5
MCV-95 MCH-29.3 MCHC-30.8* RDW-17.3* Plt Ct-451*
[**2135-5-30**] 06:50AM BLOOD WBC-10.4 RBC-4.82 Hgb-14.2 Hct-46.3
MCV-96 MCH-29.4 MCHC-30.6* RDW-18.6* Plt Ct-463*
[**2135-5-31**] 12:21PM BLOOD WBC-10.8 RBC-3.94* Hgb-11.9* Hct-38.8*
MCV-98 MCH-30.2 MCHC-30.6* RDW-18.9* Plt Ct-327
[**2135-6-1**] 01:50AM BLOOD WBC-9.8 RBC-3.65* Hgb-10.8* Hct-34.8*
MCV-95 MCH-29.5 MCHC-31.0 RDW-17.8* Plt Ct-276
[**2135-6-1**] 04:50PM BLOOD Hct-39.5*
[**2135-6-2**] 05:51AM BLOOD WBC-11.8* RBC-3.62* Hgb-10.6* Hct-35.7*
MCV-99* MCH-29.2 MCHC-29.6* RDW-17.9* Plt Ct-206
[**2135-6-3**] 03:00AM BLOOD WBC-8.9 RBC-3.51* Hgb-10.4* Hct-33.8*
MCV-96 MCH-29.6 MCHC-30.7* RDW-17.6* Plt Ct-212
[**2135-6-4**] 04:39AM BLOOD WBC-8.0 RBC-3.70* Hgb-11.2* Hct-35.6*
MCV-96 MCH-30.4 MCHC-31.6 RDW-18.1* Plt Ct-224
[**2135-6-5**] 11:45AM BLOOD WBC-7.6 RBC-3.67* Hgb-10.7* Hct-34.9*
MCV-95 MCH-29.3 MCHC-30.8* RDW-17.2* Plt Ct-256
[**2135-6-6**] 08:40AM BLOOD WBC-7.7 RBC-3.64* Hgb-10.8* Hct-34.9*
MCV-96 MCH-29.5 MCHC-30.8* RDW-16.8* Plt Ct-274
[**2135-6-7**] 06:45AM BLOOD WBC-8.5 RBC-3.70* Hgb-10.8* Hct-35.6*
MCV-96 MCH-29.2 MCHC-30.4* RDW-16.9* Plt Ct-278
[**2135-6-8**] 04:46AM BLOOD WBC-9.8 RBC-3.62* Hgb-10.6* Hct-35.1*
MCV-97 MCH-29.2 MCHC-30.1* RDW-16.7* Plt Ct-358
[**2135-6-9**] 07:55AM BLOOD WBC-8.0 RBC-3.86* Hgb-11.4* Hct-37.2*
MCV-97 MCH-29.5 MCHC-30.6* RDW-17.8* Plt Ct-352
[**2135-6-11**] 07:35AM BLOOD WBC-9.4 RBC-3.75* Hgb-10.8* Hct-37.4*
MCV-100* MCH-28.7 MCHC-28.7* RDW-16.6* Plt Ct-426
[**2135-6-12**] 07:55AM BLOOD WBC-6.4 RBC-3.81* Hgb-10.9* Hct-38.3*
MCV-101* MCH-28.7 MCHC-28.6* RDW-16.6* Plt Ct-348
[**2135-6-13**] 05:45AM BLOOD WBC-7.1 RBC-3.79* Hgb-11.0* Hct-37.3*
MCV-98 MCH-29.0 MCHC-29.5* RDW-17.4* Plt Ct-388
[**2135-6-14**] 08:20AM BLOOD WBC-8.6 RBC-4.01* Hgb-11.6* Hct-39.7*
MCV-99* MCH-28.8 MCHC-29.1* RDW-16.6* Plt Ct-549*
[**2135-5-28**] 03:40PM BLOOD Neuts-77.2* Lymphs-16.5* Monos-5.6
Eos-0.5 Baso-0.2
[**2135-5-30**] 06:50AM BLOOD Neuts-62.1 Lymphs-26.0 Monos-10.2 Eos-0.9
Baso-0.7
.
[**2135-5-29**] 08:15AM BLOOD PT-14.1* PTT-31.2 INR(PT)-1.2*
[**2135-5-30**] 11:00PM BLOOD PT-14.2* PTT-62.1* INR(PT)-1.2*
[**2135-5-31**] 12:21PM BLOOD PT-13.3 PTT-35.5* INR(PT)-1.1
[**2135-6-1**] 01:50AM BLOOD PT-12.6 PTT-56.8* INR(PT)-1.1
[**2135-6-2**] 05:51AM BLOOD PT-14.0* PTT-56.7* INR(PT)-1.2*
[**2135-6-2**] 06:30PM BLOOD PT-14.0* PTT-74.7* INR(PT)-1.2*
[**2135-6-3**] 03:00AM BLOOD PT-13.9* PTT-64.5* INR(PT)-1.2*
[**2135-6-3**] 12:00PM BLOOD PT-14.4* PTT-150.0* INR(PT)-1.3*
[**2135-6-4**] 04:39AM BLOOD PT-13.6* PTT-40.2* INR(PT)-1.2*
[**2135-6-4**] 02:30PM BLOOD PT-13.9* PTT-39.9* INR(PT)-1.2*
[**2135-6-5**] 02:00AM BLOOD PT-13.7* PTT-51.6* INR(PT)-1.2*
[**2135-6-5**] 11:45AM BLOOD PT-13.8* PTT-62.9* INR(PT)-1.2*
[**2135-6-5**] 09:43PM BLOOD PTT-55.8*
[**2135-6-6**] 04:30PM BLOOD PTT->150*
[**2135-6-6**] 08:55PM BLOOD PT-13.4 PTT-36.8* INR(PT)-1.1
[**2135-6-6**] 11:32PM BLOOD PT-13.7* PTT-33.8 INR(PT)-1.2*
[**2135-6-7**] 06:45AM BLOOD PT-14.0* PTT-42.6* INR(PT)-1.2*
[**2135-6-13**] 05:45AM BLOOD PT-13.8* PTT-28.2 INR(PT)-1.2*
.
[**2135-5-28**] 03:40PM BLOOD Glucose-132* UreaN-27* Creat-6.2* Na-134
K-3.9 Cl-100 HCO3-17* AnGap-21*
[**2135-5-29**] 08:15AM BLOOD Glucose-88 UreaN-39* Creat-8.3*# Na-138
K-4.2 Cl-101 HCO3-17* AnGap-24*
[**2135-5-29**] 01:50PM BLOOD Glucose-76 UreaN-42* Creat-8.4* Na-135
K-4.6 Cl-100 HCO3-16* AnGap-24*
[**2135-5-30**] 06:50AM BLOOD Glucose-102 UreaN-57* Creat-9.7*# Na-136
K-5.7* Cl-100 HCO3-17* AnGap-25*
[**2135-5-31**] 12:21PM BLOOD Glucose-82 UreaN-27* Creat-6.5*# Na-141
K-4.8 Cl-109* HCO3-18* AnGap-19
[**2135-6-1**] 01:50AM BLOOD Glucose-87 UreaN-31* Creat-7.5* Na-138
K-5.3* Cl-105 HCO3-18* AnGap-20
[**2135-6-2**] 05:51AM BLOOD Glucose-90 UreaN-21* Creat-5.5*# Na-139
K-4.2 Cl-104 HCO3-24 AnGap-15
[**2135-6-3**] 03:00AM BLOOD Glucose-83 UreaN-32* Creat-7.0*# Na-140
K-4.7 Cl-104 HCO3-19* AnGap-22*
[**2135-6-4**] 04:39AM BLOOD Glucose-74 UreaN-18 Creat-5.2*# Na-139
K-4.0 Cl-102 HCO3-25 AnGap-16
[**2135-6-5**] 11:45AM BLOOD Glucose-57* UreaN-37* Creat-7.2*# Na-139
K-4.0 Cl-101 HCO3-23 AnGap-19
[**2135-6-6**] 08:40AM BLOOD Glucose-95 UreaN-25* Creat-5.5*# Na-140
K-3.0* Cl-102 HCO3-24 AnGap-17
[**2135-6-7**] 06:45AM BLOOD Glucose-78 UreaN-27* Creat-6.2* Na-139
K-4.5 Cl-105 HCO3-22 AnGap-17
[**2135-6-8**] 04:46AM BLOOD Glucose-69* UreaN-32* Creat-6.6* Na-140
K-4.1 Cl-105 HCO3-21* AnGap-18
[**2135-6-9**] 07:55AM BLOOD Glucose-81 UreaN-22* Creat-5.5*# Na-142
K-4.4 Cl-106 HCO3-24 AnGap-16
[**2135-6-11**] 07:35AM BLOOD Glucose-77 UreaN-32* Creat-6.6*# Na-138
K-5.2* Cl-103 HCO3-21* AnGap-19
[**2135-6-12**] 07:55AM BLOOD Glucose-62* UreaN-23* Creat-5.0*# Na-142
K-4.6 Cl-110* HCO3-20* AnGap-17
[**2135-6-13**] 05:45AM BLOOD Glucose-64* UreaN-38* Creat-6.5*# Na-138
K-4.6 Cl-106 HCO3-19* AnGap-18
[**2135-6-14**] 08:20AM BLOOD Glucose-64* UreaN-55* Creat-8.0*# Na-138
K-5.3* Cl-104 HCO3-17* AnGap-22*
.
[**2135-6-11**] 07:35AM BLOOD ALT-6 AST-23 AlkPhos-167* TotBili-0.3
.
[**2135-5-29**] 08:15AM BLOOD Calcium-11.3* Phos-8.0* Mg-2.9*
[**2135-5-29**] 01:50PM BLOOD Albumin-3.5 Calcium-11.0* Phos-7.8*
Mg-3.6*
[**2135-5-30**] 06:50AM BLOOD Calcium-11.3* Phos-8.8* Mg-3.1*
[**2135-5-31**] 12:21PM BLOOD Calcium-9.5 Phos-7.7* Mg-2.9*
[**2135-6-1**] 01:50AM BLOOD Calcium-9.9 Phos-9.8*# Mg-2.1
[**2135-6-2**] 05:51AM BLOOD Calcium-10.0 Phos-7.8*# Mg-1.8
[**2135-6-3**] 03:00AM BLOOD Calcium-9.2 Phos-9.3* Mg-2.0
[**2135-6-4**] 04:39AM BLOOD Calcium-9.1 Phos-5.8*# Mg-1.9
[**2135-6-5**] 11:45AM BLOOD Calcium-9.6 Phos-7.6*# Mg-2.2
[**2135-6-6**] 08:40AM BLOOD Albumin-3.4 Calcium-9.5 Phos-4.7*# Mg-2.0
[**2135-6-7**] 06:45AM BLOOD Calcium-10.6* Phos-6.2* Mg-2.3
[**2135-6-8**] 04:46AM BLOOD Calcium-10.3* Phos-6.3* Mg-2.3
[**2135-6-9**] 07:55AM BLOOD Calcium-10.1 Phos-5.0* Mg-2.2
[**2135-6-11**] 07:35AM BLOOD Albumin-3.2* Calcium-10.2 Phos-7.9*#
Mg-2.3
[**2135-6-12**] 07:55AM BLOOD Calcium-9.2 Phos-4.7*# Mg-2.0
[**2135-6-13**] 05:45AM BLOOD Calcium-9.4 Phos-6.1* Mg-2.3
[**2135-6-14**] 08:20AM BLOOD Calcium-9.6 Phos-7.2* Mg-2.6
.
[**2135-5-30**] 01:00PM BLOOD PTH-628*
.
[**2135-5-30**] 07:19AM BLOOD pH-7.31* Comment-GREEN
.
[**2135-5-28**] 03:55PM BLOOD Glucose-122* K-3.8
[**2135-5-30**] 09:27PM BLOOD Glucose-105 Lactate-1.2 Na-142 K-3.5
Cl-109 calHCO3-22
.
[**2135-5-30**] 09:27PM BLOOD Hgb-14.2 calcHCT-43
[**2135-5-30**] 07:19AM BLOOD freeCa-1.33*
.
WOUND CULTURE (Final [**2135-6-1**]):
ESCHERICHIA COLI. >15 colonies.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Blood Culture x 2 ([**6-1**]) - no growth
Blood Culture [**6-11**] and [**6-12**] - no growth to date
.
EKG ([**5-28**]) - Sinus rhythm. Possible biatrial abnormality.
Compared to the previous tracing of [**2135-5-17**] there is no
significant change.
.
Fluoroscopic guided removal/replacement of HD catheter ([**5-30**]):
1. Findings compatible with IVC thrombosis, may be chronic in
nature. Findings concerning for right atrial thrombus.
2. Successful removal of a right femoral tunneled dialysis
catheter. Triple- lumen 9 French central line placement.
3. Secondary to extensive thrombus burden, placement of dialysis
catheter was not accomplished. Transhepatic placement of
hemodialysis catheter can be attempted, when the patient is
clinically stable and can tolerate the procedure.
.
Angioplasty, Tunneled HD (R femoral) catheter placment, Midline
placement ([**5-31**]):
1. Successful balloon angioplasty of the IVC with 8, 12 and
14-mm balloons.
2. Followup venogram demonstrated good angiographic result.
3. Successful placement of a 55 cm 15.5-French double-lumen
dialysis line with tip at the right atrium and the line is ready
for use.
4. Successful placement of a double-lumen lumen PICC line via
the right brachial vein with tip at the level of the axillary
vein. The line is ready for use.
.
Echocardiogram: The left atrium is normal in size. No mass or
thrombus is seen in the right atrium or right atrial appendage.
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. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. There is moderate
thickening of the mitral valve chordae. Trivial 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 no pericardial effusion.
The proximal inferior vena cava up to the junction with the
right atrium is filled with echodensity consistent with
thrombus. However, the echodensity does not appear to extend
into the right atrium itself.
Compared with the findings of the prior study (images reviewed)
of [**2134-10-13**], echodensities in the inferior vena cava
are now seen.
Brief Hospital Course:
50 year old man with history of end stage renal disease
secondary to amyloidosis, paroxysmal atrial fibrillation, Type 2
diabetes on insulin admitted for dysfunction of hemodialysis
line, transferred to ICU for hypotension after hemodialysis (3kg
taken off) and fentanyl during interventional radiology
procedure to declot and replace hemodialysis line.
.
# End Stage Renal Disease:
- last hemodialysis [**6-14**], right femoral tunneled catheter
functioning well
- renal to attempt to clear catheter with local tPA failed ->
interventional radiology for catheter change [**5-30**] ->
hypotension, extensive clot burden in right femoral vein through
inferior vena cava up to right atrium -> ICU [**Date range (1) 22380**]
- Dialysis catheter tip growing E. Coli, sensitive to
Ceftazidime, received 1g qHD for 2 weeks after catheter removed,
last dose given in in dialysis [**6-14**]
- Right groin catheter in place functioning for now
- sevelamer, cinacalcet, nephrocaps
- Family meeting [**6-6**], decided on placement of peritoneal
dialysis and placement of patient in facility that could perform
peritoneal dialysis.
- status post peritoneal dialysis catheter placement [**6-10**], needs
2-3 weeks to heal prior to use, renal doctor [**First Name (Titles) **] [**Last Name (Titles) 11197**] as
outpatient.
.
# Finger ischemia: consistent with history of extensive
microvascular disease. No anticoagulation - see rationale below.
- status post Plastic Surgery consult - appreciate input - no
surgery for now, awaiting demarcation, finger segment will
likely autoamputate. No signs of infection necessitating
amputation during this hospitalization.
.
# Thrombosis:
- Extensive inferior vena cava burden to level of right atrium
and likely involvement of superior vena cava. Risk associated
with anticoagulation in this patient related to history of
hemodynamically signficant epistaxis, recurrent epistaxis, and
hemoptysis related to fungal lesion in left upper lobed of the
lung.
- Maintained active type and screen in blood bank
- Heparin gtt was started after extensive clot discovered,
stopped given epistaxis, possible hemoptysis vs. swallowed
blood, peri-catheter oozing [**6-6**]. Patient hemodynamically
stable. Hematocrit 34.9->36.7 (dialysis in between draws). Will
not anticoagulate now after discussing risks and benefits in
family meeting on [**6-6**].
.
# Leukocytosis:
- No fevers and no signs or symptoms to suggest infection.
- WBC 12.8 early in hospital course, now no elevation in WBC
- Treated for E. Coli sepsis after grew on HD cath tip with
Ceftazidime as above
- Blood cultures 4/30 - no growth (final)
- Blood cultures 5/10, [**6-12**] pending - were drawn after mildly
hypotensive following dialysis, had no fever/WBC elevation
.
# Hypotension & tachycardia:
Most likely due to fluid removal from dialysis + fentanyl.
Sepsis also in DDx, especially with leukocytosis. Considered
bleeding while on heparin gtt, adrenal insufficiency given
chronic steroids for sarcoidosis.
- Hemodialysis end goal weight increased
- Blood cultures 4/30 - no growth (final)
- Triggered [**6-1**] for BP 60/Doppler -> 80s systolic after 1.5L,
no signs of active bleeding, mentating at baseline, hematocrit
stable
- Morphine discontinued as likely contributed to hypotension -
now oxycodone for finger pain
- Still mildly hypotenisve post-hemodialysis, asymptomatic,
pressure responds to IV fluids
.
# Sarcoidosis:
- on chronic prednisone
.
# Pulmonary aspergillosis:
- on chronic suppressive voriconazole
.
# h/o MRSA bacteremia:
- no evidence of active infection
- continue DS bactrim x 4 with HD for suppressive therapy
- followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] as outpatient
.
# Paroxysmal Atrial fibrillation:
- metoprolol 12.5 mg po 2x/day for rate control as outpatient,
had been held in setting of hypotension -> restarted [**6-1**] AM
(held for systolic < 100)
- initially no anticoagulation given history of bleeds ->
started heparin gtt with discovery of extensive thrombosis ->
heparin discontinued [**6-6**] given mild nosebleed/hemoptysis/ooze
from femoral catheter
.
# Type 2 Diabetes
- Continued glargine at 8 units HS with SSI
- Fingersticks good range when eating, hypoglycemic when NPO for
catheter placement
.
# Possible Asthma: on albuterol PRN
.
# Recent nosebleeds:
- per ENT consult on last admission, humidified air as much as
possible, nasal saline spray Q2h, bacitracin to each
nostril and massage gently for a few seconds qam and qhs.
- Epistaxis precautions, including no straining, nose blowing,
or temperature hot foods. Light activity only. Colace or other
stool softener on a regular basis.
.
# Constipation: Standing Colace, Senna, Dulcolax (made standing
[**6-6**]); PRN Lactulose added [**6-6**] -> had bowel movement
.
# GERD: PPI
.
# FEN: renal, diabetic, low potassium diet
.
# PPx: PPI, bowel regimen, held anticoagulation
.
# Code: FULL (confirmed with patient)
Medications on Admission:
Albuterol nebs
B Complex-Vitamin C-folic acid
Cinacalcet 30mg daily
Glargine 8 units HS
Lispro SSI QID
Metoprolol 12.5mg [**Hospital1 **]
Omeprazole 20mg daily
Prednisone 5mg daily, 2.5mg QHS
Sevelamer 800mg TID
Bactrim 800mg-160mg 4 tablets after each HD
Voriconazole 200mg Q12h
Acetaminophen PRN
Docusate 100 [**Hospital1 **] PRN
Senna [**Hospital1 **] PRN
Bacitracin [**Hospital1 **] to prevent nosebleeds
Oxymetazoline 0.05% spray PRN nosebleed
Sodium chloride aerosol to prevent nosebleeds
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for
shortness of breath.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for systolic blood pressure < 100, heart rate
< 60.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO every morning.
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four (4)
Tablet PO QHD (each hemodialysis): To be given prior to
dialysis.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for to prevent nosebleeds.
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for nosebleeds.
12. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: do not exceed 2g in a 24 hour period.
14. Lantus 100 unit/mL Cartridge Sig: Eight (8) units
Subcutaneous at bedtime: and sliding scale as indicated on
printout.
15. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
17. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day) as needed for constipation.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
21. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal
QID (4 times a day).
22. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO daily ().
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**]
Discharge Diagnosis:
E coli septicemia, catheter related bloodstream infection
IVC thrombosis
Chronic kidney disease stage 5
Epistaxis, hemoptysis
Finger gangrene, peripheral arterial disease
Secondary Diagnoses: Sarcoidosis, Amyloidosis, Pulmonary
Aspergillosis, Paroxysmal atrial fibrillation
Discharge Condition:
Afebrile with stable vital signs. Functioning HD catheter.
Discharge Instructions:
You were admitted when you hemodialysis line was found to be
clogged. While here, you were found to have extensive blood
clot in the veins from the catheter up to your heart. The veins
were opened in order to place another catheter. The initial
catheter was infected and you were treated with antibiotics for
the infection. You received blood thinners for a time after the
clots were found, but because of nosebleeds and bleeding from
your catheter site, the heparin was stopped. The care team
together with you and your family decided that the risk of
bleeding was too high to continue. You had a peritoneal
dialysis catheter placed while you were here. It will take [**3-6**]
weeks until this heals and can be used. Until then, you will
receive hemodialysis through the current line. Your left pinky
finger became ischemic, there were no signs of infection and it
will likely fall off on its own. You should follow up in the
hand clinic.
- Call your doctor or return to the hospital if you experience
chest pain, trouble breathing, fevers/chills, inability to eat,
severe abdominal pain, foul smelling drainage or pus from your
finger or your catheter sites.
- Continue your dialysis at [**Location (un) **] in [**Location (un) **] as scheduled
until you are receiving peritoneal dialysis
Followup Instructions:
Please continue to follow-up with your nephrologist and with
your dialysis treatments. If you develop foul smelling
discharge or drainage/pus from your ischemic finger, you can
follow up at the [**Hospital1 18**] hand clinic, the phone number is
([**Telephone/Fax (1) 88616**].
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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20477, 20527
|
12669, 17625
|
310, 403
|
20847, 20909
|
2905, 12646
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22258, 22540
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2193, 2248
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18171, 20454
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20548, 20720
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17651, 18147
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20933, 22235
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2263, 2886
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20742, 20826
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241, 272
|
431, 1143
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1165, 1827
|
1843, 2177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,658
| 156,696
|
37429
|
Discharge summary
|
report
|
Admission Date: [**2148-12-3**] Discharge Date: [**2148-12-20**]
Date of Birth: [**2069-6-17**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
arrived intubated
History of Present Illness:
Ms. [**Known lastname 84122**] is a 79 year-old right-handed woman with a past
medical history including TIA, memory loss and right retinal
detachment who presents from [**Hospital3 7571**]Hospital with
intraparenchymal hemorrhage.
The patient's family explains that Ms. [**Known lastname 84122**] was in her usual
state of health on [**2148-12-2**] at about 5 pm when her son-in-law
stopped by to help administer some eye drops. The family next
returned at about 11 pm and found the patient "unresponsive" and
lying on the couch with her living [**Doctor First Name 84123**] in slight disarray.
Her
son-in-law recalls tapping her and calling her name without
appreciable response initially. However, he subsequently found
that she was able to look "straight at" him and follow his
request to grip his hand. Concerned that she was not moving the
right side of her body and apparently unable to speak, he called
911.
The patient was initially transported to an [**Hospital3 **],
where a non-contrast CT of the head reportedly revealed a left
frontal intrapanchymal hemorrhage with intraventricular
extension
and 7mm midline shift to the right in addition to a left
occipital lobe hemorrhage. She was given dilantin 1 gram IV,
fentanyl 250 mcg, 3% hypertonic saline (quantity unkown), and
mannitol 1 gram IV x 1. After intubation, she was flown to the
[**Hospital1 18**] for further evaluation and care.
At the time of her arrival, her family explains that she is
relatively independent at baseline. She lives alone and is able
to perform activities of daily living. Her family does note,
however, a decline in her general ability to function in the few
months prior to admission. Her family also recently got her a
walker to encourage steady ambulation.
Past Medical History:
- right retinal detachment, s/p repair in week PTA
- memory loss
- TIA - carotid US reportedly clean per family
- osteoporosis
- osteoarthritis
- torn meniscus (right knee)
Social History:
- lives independently
- two daughters
- per family years long memory difficulty and cognitive decline,
worse after she lost her husband last [**Name2 (NI) **].
Family History:
- TIA (mother)
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T: not recorded P: 64 R: not recorded BP: 125/61
SaO2:
100%
General: Ill-appearing, Intubated
HEENT: Intubated
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: coarse breath sounds bilaterally anteriorly.
Abdomen: Obese. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: does not respond to verbal stimuli. Does
not follow commands.
Cranial Nerves:
* I: Olfaction not evaluated.
* II/III: Right pupil round, 6 mm, unresponsive to light (per
ED
this is baseline since surgery), left pupil round, 1.5 --> 1 mm
with light.
* V/VII: Corneal reflexes intact bilaterally (much more brisk on
left than on right)
* VII: ? flattening right nasolabial fold
* IX, X: Gag/cough intact
* Doll's Eyes: negative
Motor:
* Bulk: No evidence of atrophy.
* ?Increased rigidity right upper extremitiy
Strength:
* Able to withdraw lower extremities, left upper extremitie at
least versus gravity with noxious --> later spontaneously
Reflexes:
* Left: 2 throughout Biceps, 2 Patellar
* Right: 2+ thoughout Biceps, 2 Patellar
* Babinski: extensor bilaterally
Sensation:
* Noxious Stimulation: Withdraws lower extremities, left upper
extremity
Coordination
* Unable to specifically assess
Gait:
* unable to assess
Pertinent Results:
[**2148-12-3**] 02:02AM BLOOD WBC-8.2 RBC-3.30* Hgb-10.5* Hct-31.4*
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.0 Plt Ct-218
[**2148-12-3**] 07:20AM BLOOD Glucose-110* UreaN-9 Creat-0.6 Na-136
K-4.2 Cl-104 HCO3-22 AnGap-14
[**2148-12-3**] 07:20AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.9 Cholest-PND
[**2148-12-3**] 02:02AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
CT [**2148-12-3**]:
Large areas of intraparenchymal hemorrhage involving the left
basal ganglia extending into the left frontal lobe and also
involving the left occipital lobe, favor amyloid angiopathy,
versus hypertensive, though mass or AVMs cannot be entirely
excluded. Stable since recent reference examination.
CTA
1. Interval increase in left frontal lobe hemorrhage and
associated mass
effect with stable left parieto-occipital and intraventricular
blood.
2. No underlying aneurysm or vascular malformation is
identified.
3. High-attenuation filling the right globe, which may represent
acute
hemorrhage or a chronic process and should be correlated with
the patient's
history.
Brief Hospital Course:
Ms. [**Known lastname 84122**] is a 79 yera-old right-handed woman with a past
medical history including TIA, memory loss and right retinal
detachment who presents from an [**Hospital6 17032**]
with intraparenchymal hemorrhage. Clinical examination is
notable for an ill-appearing intubated woman with an
unresponsive right
surgical pupil, absence of movement in the right upper
extremity,
and bilateral extensor responses. Neuroimaging reveals
intraparenchymal hemorrhages in the left basal ganglia, with
extension into the left frontal lobe, and left occipital lobe.
Given the patient's history of memory difficulty and congnitive
decline over the past 1-2 years the hemorrhage is likely
secondary to amyloid
angioathy, in the setting of aspirin use.
The patient was admitted and sent to the Neuro ICU. She was
intitally started on Mannitol and then transitioned over to
hypertonic saline for management of raised ICP. A repeat head
CT showed a stable bleed with surrounding edema. The patient
was slowly weaned off Mannitol and her Keppra was decreased as
well.
After discussion with the family the patient was made DNR on
[**12-9**]. She was made comfort measures only on [**12-11**]. She expired
on [**2148-12-20**].
Medications on Admission:
- aricept 10 mg po daily
- asa 81 mg po daily
- vit D 1000 IU po daily
- gantifloxacin 5 ml OD QID
- prednisolone 10 ml OD QID
- boniva details unknown
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
2. Morphine (PF) in D5W 100 mg/100 mL (1 mg/mL) Parenteral
Solution Sig: One (1) Intravenous INFUSION (continuous
infusion).
3. Lorazepam 1 mg IV Q1H:PRN CMO
4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
once a day.
Discharge Disposition:
Expired
Discharge Diagnosis:
parenchymal hemorrhage centered within the left basal ganglia
and extending to the left frontal, parietal and occipital lobes,
mass effect on the left lateral ventricle, rightward shift of
midline structures and mild subfalcine herniation
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic and not arousable
Activity Status:Bedbound
Discharge Instructions:
You were admitted for evaluation of stroke. You had CT scan of
your brain which showed parenchymal hemorrhage centered within
the left basal ganglia and extending to the left frontal,
parietal and occipital lobes, mass effect on the left lateral
ventricle, rightward shift of midline structures and mild
subfalcine herniation.
It was decided to change you goals of care to comfort measures
only as per family meeting.
Followup Instructions:
-
|
[
"431",
"348.5",
"V12.54",
"518.81",
"733.00",
"599.0",
"277.30",
"348.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6911, 6920
|
5108, 6338
|
354, 373
|
7203, 7203
|
4003, 5085
|
7780, 7785
|
2557, 2573
|
6541, 6888
|
6941, 7182
|
6364, 6518
|
7337, 7757
|
2588, 2588
|
2610, 2987
|
286, 316
|
401, 2167
|
3129, 3984
|
7217, 7313
|
3011, 3011
|
2189, 2364
|
2380, 2541
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,171
| 103,075
|
25464+25490
|
Discharge summary
|
report+report
|
Admission Date: [**2174-8-7**] Discharge Date: [**2174-8-10**]
Date of Birth: [**2156-8-20**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Motor vehicle accident, rollover, ejected, cardiac arrest in the
field, resuscitated and intubated, hypotensive on arrival to
trauma bay.
Major Surgical or Invasive Procedure:
Intracranial monitor by neurosurgery service on [**8-7**]
Exploratory laparotomy [**8-7**]
History of Present Illness:
The patient was the intoxicated unrestrained driver of a high
speed motor vehicle involved in a rollover accident. He was
ejected and without vital signs at the scene. He was
resuscitated and brought to [**Hospital1 18**].
Past Medical History:
R arm surgery
Social History:
Multisubstance abuser
Physical Exam:
Vitals: HR 87 BP122/71 s02 99% ventilated T
General: intubated, sedated, multiple lacerations all over
Skin: multiple lacerations and bruises over his face; ecchymoses
R eye
Head, ear, nose and throat: multiple bruises; intubated\
Lungs: vented breathing sounds; L-pneumothorax; drains in place
Cardiovascular: S1 S2 regular, no murmur
Abdomen: decreased bowel sounds, s/p surgery
Extremities: slightly edematous in all 4 extremities; multiple
lacerations
Pertinent Results:
[**8-7**] Head CT: Diffuse cerebral edema and loss of [**Doctor Last Name 352**]-white
differentiation in the left temporal lobe and parieto-occipital
regions. Diffuse loss of ventricles and sulci, suggesting uncal
herniation. This was discussed with the trauma surgery team on
call
[**8-7**] Abd CT: 1. Fracture of the T6 vertebral body with
obliteration of the spinal canal at this point and complete
posterior dislocation of the distal vertebral column, complete
transection of the cord at this point.
2. Bilateral pneumothoraces, consolidations due to aspiration,
and probable contusions, with multiple rib fractures.
3. A small amount of pneumomediastinum.
4. Intraperitoneal free fluid, which may be consistent with
patient's recent diagnostic peritoneal lavage, but may also be
due in part to intraperitoneal blood.
5. Splenic abnormality in medial aspect, concerning for splenic
laceration; however, by report, at exploratory laparotomy,
patient's spleen was normal.
6. Diffusely edematous, markedly enhancing bowel, concerning for
shock bowel.
7. Fracture of the inferior pubic ramus.
8. Subcutaneous emphysema along the paraspinal muscles, the left
chest, and along the sites of the chest tube insertion.
Brief Hospital Course:
The patient continued to be hypotensive in the trauma bay and
was taken to the operating room for exploratory laparotomy. No
source for bleeding was identified. The patient was stabilized
with blood products and kristalloids and taken to the intensive
care unit for further care. During his hospital admission he
never regained neurological function. There was no movement of
his lower and only light posturing response to pain on his right
upper extremity. He did not regain brain stme functions such as
gag or corneal reflex. On [**8-10**], the family decided after several
meetings with the care team including the neurosurgeons to take
him of the ventilator They agreed to organ donation. He was
pronounced on [**8-10**].
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
High speed MVC with ejection and cardiac arrest in the field.
Discharge Condition:
The patient expired.
Discharge Instructions:
The patient was brought to the operating room for organ
donation.
The medical examiner has taken this case.
Completed by:[**2174-8-16**] Admission Date: [**2174-8-7**] Discharge Date: [**2174-8-10**]
Date of Birth: [**2156-8-20**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Please see discharge summary from same day. Thanks.
Major Surgical or Invasive Procedure:
Organ donation, s/p trauma.
Brief Hospital Course:
Please see complete discharge summary from same day.
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
The patient expired, please see complete discharge summary from
same day.
Discharge Condition:
Expired.
Completed by:[**2174-9-22**]
|
[
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"812.40",
"802.9",
"861.21",
"806.21",
"807.09",
"802.0",
"304.01",
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"E849.5",
"810.00",
"801.75",
"512.0",
"348.4",
"870.8",
"808.2",
"860.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.14",
"38.93",
"08.81",
"96.72",
"34.04",
"99.04",
"33.23",
"96.07",
"54.11",
"01.18"
] |
icd9pcs
|
[
[
[]
]
] |
4197, 4236
|
4120, 4174
|
4068, 4097
|
4353, 4392
|
1343, 1353
|
3365, 3371
|
4257, 4332
|
3336, 3342
|
3584, 3960
|
866, 1324
|
3977, 4030
|
551, 775
|
1362, 2560
|
797, 812
|
828, 851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,324
| 136,492
|
2503
|
Discharge summary
|
report
|
Admission Date: [**2137-5-15**] Discharge Date:[**2137-5-20**]
Service: MED
HISTORY OF PRESENT ILLNESS: This is an 86 year old female
with a past medical history of diabetes, hypertension,
hypercholesterolemia, and a history of syncope who was
admitted on [**2137-5-14**] with slurred speech, right hand
difficulty grasping, and mental confusion for the past two
days. The slurred speech and hand difficulty grasping were
of about 15 minutes duration and then improved. The patient
was taken to the Emergency Room for further evaluation, in
the Emergency Room she was noted to have a heart rate of 30
during micturition and then subsequently had a loss of
consciousness with spontaneous resolution. The patient had
recurrent episodes of bradycardia which prompted intubation
for airway protection. The patient was treated for
hypertensive urgency with systolic blood pressures in the
200s and responded to therapy. The patient prior to
intubation had no complaints and was admitted to the Medical
Intensive Care Unit for further management.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypercholesterolemia.
3. Hypertension.
4. Blindness secondary to bilateral cataracts.
5. She had an episode of syncope in [**2132**], details of the
workup are unknown.
PAST SURGICAL HISTORY: She has had a total abdominal
hysterectomy.
MEDICATIONS AT HOME: She had been on aspirin 81 mg p.o.
q.d., Lipitor 60 p.o. q.d., Diovan 160 mg p.o. b.i.d.,
Metformin 1000 mg p.o. b.i.d., Lente 50 units q. AM, 5 units
q.h.s., Neurontin q.h.s.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with her daughter. She does not
drink, smoke or do drugs.
FAMILY HISTORY: She has no history of coronary artery
disease. Otherwise family history was unremarkable.
PHYSICAL EXAMINATION: Physical examination on admission
revealed temperature was 99.0, heart rate was 94, blood
pressure 240/98, respiratory rate 16. She was 96 percent on
room air. In general, she was an elderly female in no
apparent distress. She was speaking in short sentences.
Head, eyes, ears, nose and throat, her neck was supple, there
was no jugular venous distension. Cardiovascular, she has a
regular rate and rhythm, II/VI systolic murmur. Lungs were
clear to auscultation bilaterally. Abdomen was soft,
nontender, nondistended. There were no masses present.
Exsanguinate, she had no lower extremity edema. Neurological
examination, cranial nerves III through XII were symmetrical
and intact. She had normal muscle tone. She had 5 out of 5
strength in bilateral upper extremities. The patient was
uncooperative with testing of the lower extremities. The
patient had slowed left upper extremity, random alternating
movements and left-sided dysmetria on finger-to-nose testing.
Her sensation was intact to light touch proximally and
distally in the upper and lower extremities and her sensation
was intact throughout.
LABORATORY DATA: The patient's laboratory data on admission
revealed her complete blood count was within normal limits,
her chem-7 was within normal limits. A urinalysis was done
which was negative. Cardiac enzymes were sent and the first
set was negative. A urine toxicology screen was sent and was
negative. An electrocardiogram prior to the episode of
bradycardia showed normal sinus rhythm at 91 beats/minute,
normal intervals, no acute change from previous
electrocardiogram. Electrocardiogram after the bradycardia,
she was normal sinus rhythm at 81 beats/minute. She had
increase in her QTC interval and she had some upsloping ST
segments. Chest x-ray on admission, she has no evidence of
pneumonia or congestive heart failure. She had some densely
calcified lymph nodes on the right side which were unchanged
from previous electrocardiograms. She had a head
computerized tomography scan done which showed no evidence of
ICH. She did have some chronic periventricular white matter
disease. She had an magnetic resonance imaging/magnetic
resonance angiography done which was negative for any
evidence of stroke. The patient was transferred to the
Medicine Intensive Care Unit for further care.
HOSPITAL COURSE:
1. Neurologic - The patient's neurologic deficit seemed to
improve over time, though this is a was felt that she had
an episode of reversible ischemic neurologic defect. The
patient was seen by the Neurology Service who recommended
starting Aggrenox. The patient's neurologic examination
continued to improve throughout her admission. Her mental
status slowly returned towards her baseline. The patient
had an echocardiogram done on [**2137-5-15**], which showed
that she had a hyperdynamic left ventricle ejection
fraction with 70 to 80 percent. She had symmetric left
ventricular hypertrophy. She had impaired relaxation but
there was no evidence of clot. She had carotid dopplers
done on [**5-17**], which showed minimal bilateral internal
carotid artery plaques but there was no appreciable
stenosis.
1. Cardiovascular - The patient had been started in the
Emergency Room on a Nipride drip for her hypertension.
The patient came off of the Nipride drip in 24 hours and
was resumed on her outpatient blood pressure regimen. Her
blood pressure goal was between 140 and 160 systolic.
1. Bradycardia in the setting of micturition - The
Electrophysiology Service was consulted and they felt that
this was consistent with a vasovagal syncope. The patient
was started on Atenolol 25 mg p.o. q.d. She had no
further episodes of bradycardia in the hospital. She will
need an outpatient [**Doctor Last Name **] of Hearts Monitor.
1. Pulmonary - The patient was intubated for airway
protection on [**2137-5-14**]. She was extubated on [**2137-5-15**]. A post extubation film showed some left lower lobe
atelectasis and a small effusion. The patient's oxygen
saturations were stable on room air. No further workup
was done.
1. Diabetes - The patient was on an insulin drip while in the
Intensive Care Unit. He was then changed over to an
equivalent dose of standing Lente with sliding scale
insulin, however, the patient's blood sugars were poorly
controlled, so she was converted over to Glargine and her
dose was titrated up for a goal fingerstick of 80 to 120.
1. Renal - The patient has chronic renal insufficiency and
she has a renal tubular acidosis. Her creatinine remained
at her baseline throughout her admission.
1. Fluids, electrolytes and nutrition - The patient was seen
by the Speech and Swallow Service. The patient was able
to tolerate oral intake. Their recommendations were a
diet of thin liquids via cup sips and soft solids and
aspiration precautions. We will have the Speech and
Swallow Service re-evaluate the patient prior to
discharge.
1. Physical therapy - The patient was seen by physical
therapy and occupational therapy. It was recommended that
the patient go either to a rehabilitation facility or to a
nursing home for longterm care, given her mental status is
continuing to wax and wane at times. This is not far from
the patient's baseline per the family. She would often
awaken with episodes of confusion. The patient's health
care proxy is her daughter [**Name (NI) 12808**], whose phone number is
[**Telephone/Fax (1) 12809**].
DISCHARGE INSTRUCTIONS: Take all medications as instructed.
Follow up as below.
DISCHARGE DIAGNOSIS:
1. Reversible ischemic neurologic defect.
2. Hypertension.
3. Diabetes mellitus.
4. Vasovagal syncope.
5. Chronic renal insufficiency.
FOLLOW UP: She is to follow up with Dr. [**Last Name (STitle) **] on [**5-31**], at
9:30 AM.
MAJOR SURGICAL OR INVASIVE PROCEDURES: She had intubation
done. She had a computerized tomography scan of the head.
She had an magnetic resonance imaging/magnetic resonance
angiography and she had an arterial line placed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Valsartan 160 mg p.o. b.i.d.
2. Atorvastatin 60 mg p.o. q.d.
3. Heparin 5000 units q. 12 hours until ambulatory.
4. Aggrenox one capsule p.o. b.i.d.
5. Hydrochlorothiazide 25 mg p.o. q.d.
6. Atenolol 25 mg p.o. q.d.
7. Timolol drops one drop to each eye b.i.d., 0.25 percent
solution.
8. Nifedipine 30 mg p.o. b.i.d.
9. Acetaminophen prn.
10. Colace.
11. Senna.
12. Protonix 40 mg p.o. q.d.
[**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **]
Dictated By:[**Location (un) 5618**]
MEDQUIST36
D: [**2137-5-19**] 16:16:30
T: [**2137-5-19**] 17:55:26
Job#: [**Job Number 12810**]
|
[
"250.42",
"518.0",
"435.9",
"250.62",
"401.0",
"272.0",
"366.9",
"357.2",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1682, 1774
|
7996, 8642
|
7482, 7619
|
4147, 7379
|
7404, 7461
|
1363, 1578
|
1296, 1341
|
7631, 7939
|
1797, 4130
|
117, 1060
|
1082, 1272
|
1595, 1665
|
7964, 7973
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,948
| 149,101
|
53066+59492+59493+59494
|
Discharge summary
|
report+addendum+addendum+addendum
|
Admission Date: [**2197-1-4**] Discharge Date: [**2197-1-18**]
Date of Birth: [**2117-2-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Procainamide / niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2197-1-6**]
1. Mitral valve replacement with a 33-mm St. [**Male First Name (un) 923**] Epic mitral
valve bioprosthesis, serial #[**Serial Number 109338**], reference #[**Serial Number 109339**].
2. Tricuspid valve repair with an [**Doctor Last Name **] 32-mm MC cubed ring,
serial #[**Serial Number 109340**], model #4900.
3. Coronary bypass grafting x1 with a reverse saphenous vein
graft from aorta to the posterior descending coronary artery.
4. Atrial septal defect repair with bovine pericardium.
History of Present Illness:
Delightful 79 year old gentleman with a history of mitral valve
regurgitation diagnosed in [**2192**] and followed by serial
echocardiograms. Over the past year, he has been admitted to the
hospital 6 times for congestive heart failure and has also
required a continuous infusion of lasix. He is now taking
torsemide 100mg daily. In addition he goes to infusion clinic
for IV diuresis. Because of his chronic myelogenous leukemia,
advanced chronic kidney disease and low EF, he has been
considered a poor surgical candidate for corrective intervention
on the mitral valve. However, because of repetitive
hospitalizations over the past year, it is felt to be time to
consider a high-risk corrective surgery.
Past Medical History:
Mitral and tricuspid regurgitation, coronary artery disease and
atrial septal defect s/p Mitral valve replacement, tricuspid
valve repair and coronary artery bypass graft x 1, atrial septal
defect repair
Past medical history:
-chronic myelogenous leukemia on Gleevec
-s/p ICD implantation [**10-28**], h/o VT, EF 25% (echo [**3-30**])
-Chronic Kideney Disease - baseline Cr 2.5 - today 3.2
-Coronary Artery Disease, h/o Inferior Myocardial Infarction
late [**2155**]'s, cath [**2183**] - RCA 90% proximal, totally occluded
distally, akinetic inferoposterior segment, EF 25-30% ([**3-30**])
-Bilateral hearing aides
-Lumbar disc disease
-Depression
-Anemia
-[**2177**] CVA d/t LV thrombus - no residual deficits
-Congestive Heart Failure, TTE [**3-30**] - LVEF 25%, severe global
LV hypokinesis, 4+ MR, 3+ TR, mild pulmonary hypertension.
- being worked up as outpatient for pulmonary nodule ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 575**] thinks this is a nonmalignant finding, probably
bronchiectasis)
Past Surgical History:
-ICD Implantation [**10-28**]
-Appendectomy
Social History:
Race: Caucasian
Last Dental Exam: Last week, partial dentures
Lives with: Wife
Occupation: Worked in construction, worked only part-time after
CVA in [**2178**], now retired. Was in the military.
Tobacco: Quit smoking 25 yrs ago, smoked 1 ppd x 20-25 years.
ETOH: 1 glass of wine daily
Family History:
Non-Contributory
Physical Exam:
Pulse: 85 Resp: 16 O2 sat: 98
B/P Right: 131/54 Left:
Height: 5'9" Weight: 178 lbs
General: No acute distress, uses cane for walking
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT[X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [X] Murmur soft, systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2197-1-6**] Echo: PREBYPASS: A left-to-right shunt across the
interatrial septum is seen at rest. A secundum type atrial
septal defect of approximately 8mm is present. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with dyskinesis of the basal inferior wall,
severe hypokinesis/akinesis of the inferolateral wall and
inferoseptal walls and mild hypokinesis of the anterior,
anterolateral and anteroseptal walls. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, posterior directed
jet of The mitral regurgitation vena contracta is >=0.7cm.
Severe (4+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. An epiaortic scan showed
and anterior rim of calcification and the canulation and cross
clamp site were adjusted accordingly.
POSTBYPASS: The patient is receiving epinephrine at 0.05
ucg/kg/min. LV systolic function appears marginally improved in
the setting of inotropes (LVEF25-30%). RV systolic function is
improveed. The is a well seated, well functioning bioprosthesis
in the mitral position. There is trace valvular MR. There is a
ring prosthesis in the tricuspid position. There is trace
valvular TR. The ASD is no longer visualized. An agitated saline
bubble study revealed no intraatrial shunt at rest of with
Valsalva and release. The study is otherwise unchanged from
prebypass.
[**2197-1-16**] 06:55AM BLOOD WBC-8.8 RBC-2.93* Hgb-9.5* Hct-28.3*
MCV-97 MCH-32.4* MCHC-33.6 RDW-17.1* Plt Ct-287
[**2197-1-16**] 06:55AM BLOOD PT-25.2* PTT-26.5 INR(PT)-2.4*
[**2197-1-15**] 06:20AM BLOOD PT-24.1* PTT-27.0 INR(PT)-2.3*
[**2197-1-14**] 06:00AM BLOOD PT-19.9* INR(PT)-1.8*
[**2197-1-16**] 06:55AM BLOOD Glucose-130* UreaN-103* Creat-3.3* Na-137
K-4.1 Cl-95* HCO3-34* AnGap-12
[**2197-1-14**] 02:00PM BLOOD LD(LDH)-429* CK(CPK)-102
Brief Hospital Course:
The patient is a 79-year-old gentleman referred by Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 437**] for recalcitrant
heart failure. Workup demonstrated severe mitral regurgitation,
as well as moderate-to-severe tricuspid regurgitation and
single-vessel coronary disease. The patient was admitted to the
hospital and brought to the operating room on [**2197-1-6**] where he
patient underwent mitral valve replacement with a 33-mm St. [**Male First Name (un) 923**]
Epic mitral valve bioprosthesis, tricuspid valve repair with an
[**Doctor Last Name **] 32-mm MC cubed ring, coronary bypass grafting x1 with a
reverse saphenous vein graft from aorta to the posterior
descending coronary artery and atrial septal defect repair with
bovine pericardium. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. Electrophysiology interrogated the permanent
pacemaker post operative day 1. The patient was neurologically
intact and hemodynamically stable on no inotropic or vasopressor
support. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were discontinued
without complication. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The renal
service was consulted for post operative ATN (baseline creatine
is 3.0). Peak creatine was 4.4 and peak BUN 117. Diuretics were
decreased per renal recommendations and he was maintained on
Lasix 40 IV daily. Per renal recommendations, he is to stay on
Lasix 40 IV BID until edema decreases and then go to Lasix 40 IV
daily with renal follow up in 6 weeks. This appointment has
been arranged. He was anticoagulated for post operative atrial
fibrillation and a history of CVA due to LV thrombus. His
Coumadin was held POD 9, as the patient had epistaxis. Dr [**First Name (STitle) 437**]
was contact[**Name (NI) **] and he recommended continuing the Coumadin once
discharged with INR goal 2-2.5 (epistaxis had resolved at the
time of discharge). The patient was transferred to the
telemetry floor for further recovery. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 10 the patient was
ambulating with assistance, the wound was healing well (well
healing tape burns surrounding sternal incision) and pain was
controlled with oral analgesics. The patient was discharged to
[**Hospital3 **] in [**Location (un) 1294**] in good condition with appropriate
follow up instructions and follow up appointments arranged.
Medications on Admission:
ACAPELLA - Use as directed for 5 min two to three times a day to
help clear airways of mucus
ALLUPURINOL - (Prescribed by Other Provider) - - 100mg is one
capsule once a day
DIGOXIN - 125 mcg Tablet - one-half Tablet(s) by mouth daily
[**Location (un) 766**] through Friday
EPOETIN ALFA [EPOGEN] - (Prescribed by Other Provider) - 20,000
unit/mL Solution - 40,000 units subcutaneously once a week
FINASTERIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
GALANTAMINE - (Prescribed by Other Provider) - 8 mg Cap,24 hr
Sust Release Pellets - 1 Cap(s) by mouth daily at bedtime
HYDRALAZINE - (Prescribed by Other Provider) - 50 mg Tablet -
one-half Tablet(s) by mouth twice a day
[**Location (un) **] [GLEEVEC] - (Prescribed by Other Provider) - 400 mg
Tablet - 0.5 (One half) Tablet(s) by mouth twice a day take
during a meal with a large glass of water
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - (Dose adjustment - no new Rx) - 50 mg
Tablet Sustained Release 24 hr - one-half Tablet(s) by mouth
daily
RANITIDINE HCL - 150 mg Capsule - 1 Capsule(s) by mouth daily
RISPERIDONE - (Prescribed by Other Provider) - 2 mg Tablet -
one-half Tablet(s) by mouth
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
TORSEMIDE - (Prescribed by Other Provider) - 100 mg Tablet - 1
Tablet(s) by mouth once a day
VENLAFAXINE - (Prescribed by Other Provider) - 75 mg Tablet - 1
Tablet(s) by mouth three times a day
**WARFARIN - 2 mg Tablet - 1 Tablet(s) by mouth daily; except
Mon & Fri 2 tabs
CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider;
OTC) - 600 mg-400 unit Tablet - 2 Tablet(s) by mouth once a day
GUAIFENESIN [MUCINEX] - 600 mg Tablet Sustained Release - 1
(One) Tablet(s) by mouth twice daily
LUTEIN - (OTC) - Dosage uncertain
OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - 1,200 mg-144 mg
Capsule - 2 Capsule(s) by mouth once a day
PSYLLIUM [METAMUCIL] - (Prescribed by Other Provider; OTC) -
0.52 gram Capsule - 2 Capsule(s) by mouth once a day
Discharge Medications:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): decrease to 400 daily in 1 week then 200 mg [**Hospital1 **] x 2
weeks then 200 mg daily then continue as directed by
cardiologist.
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. galantamine 4 mg Tablet Sig: One (1) Tablet PO hs ().
12. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. [**Hospital1 **] 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
15. guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
16. lasix Sig: 40 mg IV Intravenous twice a day for 2 weeks:
then decrease to Lasix 40 IV daily.
17. [**Hospital1 **]
Please Check Chem 7 and INR daily until stable - INR goal 2-2.5
for hx CVA and atrial fibrillation
18. allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Mitral and tricuspid regurgitation, coronary artery disease and
atrial septal defect s/p Mitral valve replacement, tricuspid
valve repair and coronary artery bypass graft x 1, atrial septal
defect repair
Past medical history:
-chronic myelogenous leukemia on Gleevec
-s/p ICD implantation [**10-28**], h/o VT, EF 25% (echo [**3-30**])
-Chronic Kideney Disease - baseline Cr 2.5 - today 3.2
-Coronary Artery Disease, h/o Inferior Myocardial Infarction
late [**2155**]'s, cath [**2183**] - RCA 90% proximal, totally occluded
distally, akinetic inferoposterior segment, EF 25-30% ([**3-30**])
-Bilateral hearing aides
-Lumbar disc disease
-Depression
-Anemia
-[**2177**] CVA d/t LV thrombus - no residual deficits
-Congestive Heart Failure, TTE [**3-30**] - LVEF 25%, severe global
LV hypokinesis, 4+ MR, 3+ TR, mild pulmonary hypertension.
- being worked up as outpatient for pulmonary nodule ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 575**] thinks this is a nonmalignant finding, probably
bronchiectasis)
Past Surgical History:
-ICD Implantation [**10-28**]
-Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
2+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2197-2-7**] at 2:00 PM
Cardiologist: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2197-2-20**] at 11:30 AM
Nephrologist Dr [**Last Name (STitle) 7473**] on [**2-15**] at 8:30 AM [**Hospital Ward Name 121**] 1
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 8771**] [**Last Name (NamePattern1) **] in [**3-28**] 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**
[**Telephone/Fax (1) **]: PT/INR for Coumadin ?????? indication Atrial fibrillation / Hx
CVA
Goal INR 2-2.5
First draw [**2197-1-17**]
Completed by:[**2197-1-16**] Name: [**Known lastname 5148**],[**Known firstname 17923**] Unit No: [**Numeric Identifier 17924**]
Admission Date: [**2197-1-4**] Discharge Date: [**2197-1-18**]
Date of Birth: [**2117-2-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Procainamide / niacin
Attending:[**First Name3 (LF) 1543**]
Addendum:
The patient experienced confusion/aggitation on POD#10 prior to
discharge. The decision was made to keep the patient in house
and adjust medications and evaluate for other sources of
confusion. UA was negative. Galantamine was increased to home
dose, as was Effexor. On POD#11 mental status had improved and
patient was oriented x 3. BUN and Crea had improved and he was
maintained on Lasix 40 IV daily with decrease in peripheral
edema. INR was 2.0 and Coumadin 1 mg was given with goal INR
1.8-2.5. Plan was to evaluate mental status for an additional
day and then transfer to rehab. Plan of care was discussed with
the patient and his wife, who were in agreement.
Discharge medications include;
warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): decrease to 400 daily in 1 week then 200 mg [**Hospital1 **] x 2
weeks then 200 mg daily then continue as directed by
cardiologist.
finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
Daily).
polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
Imatinib 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
lasix Sig: 40 mg IV Intravenous once a day.
allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
venlafaxine 75 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
galantamine 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Labs
Please Check Chem 7 and INR daily until stable - INR goal
1.8-2.5 for hx CVA and atrial fibrillation
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2197-1-17**] Name: [**Known lastname 5148**],[**Known firstname 17923**] Unit No: [**Numeric Identifier 17924**]
Admission Date: [**2197-1-4**] Discharge Date: [**2197-1-18**]
Date of Birth: [**2117-2-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Procainamide / niacin
Attending:[**First Name3 (LF) 1543**]
Addendum:
Spoke with patient's hematologist who recommended Epogen 40,000
units SC every other week OR Aranesp 200 micrograms SC every
other week (which ever is available at the rehab facility). He
will receive 40,000 units Epogen SC [**2197-1-17**] with next dose due
[**2197-1-31**]. He will be scheduled for Hematology follow up.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2197-1-17**] Name: [**Known lastname 5148**],[**Known firstname 17923**] Unit No: [**Numeric Identifier 17924**]
Admission Date: [**2197-1-4**] Discharge Date: [**2197-1-18**]
Date of Birth: [**2117-2-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Procainamide / niacin
Attending:[**First Name3 (LF) 1543**]
Addendum:
Mr. [**Known lastname **] was held an extra day due to some confusion with
his narcotic pain medicine and a nose bleed. His nose bleed
resolved without issue. He was switched to tylenol for pain and
seemed to have adequate control. He was then discharged to rehab
on postoperative day 12. All follow-up appointments have been
arranged recommended. He will be discharged to [**Hospital1 **] in [**Location (un) **]. He will have telemetry while at
rehabilitation. Coumadin will be dosed for a goal INR of
2.0-2.5. He will continue and amiodarone taper to 200mg daily as
instructed on the discharge face sheet.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2197-1-18**]
|
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"414.2",
"276.2"
] |
icd9cm
|
[
[
[]
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] |
[
"39.61",
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[
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[]
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|
247, 268
|
841, 1549
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12891, 13690
|
2680, 2967
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,736
| 169,525
|
27107
|
Discharge summary
|
report
|
Admission Date: [**2134-10-8**] Discharge Date: [**2134-10-15**]
Date of Birth: [**2072-1-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
Fever, weakness, change in mental status.
Major Surgical or Invasive Procedure:
IVC filter placement.
History of Present Illness:
62 year-old female with metastatic melanoma to
liver/brain/pancreas presenting with fever and weakness after
temozolomide chemotherapy on [**2134-10-6**]. In addition, she notes
loose stools x 1 and difficulty swallowing solids. Per her
sister, two weeks PTA, she was acting normally - they visited
[**Location (un) **] together. Then, this week upon completion of
chemotherapy, she developed a fever to 101 at home and
progressive weakness to the point that she could not get out of
bed.
.
In the ED, VS Tmax 101.8, HR 111, BP 146/78, RR 16, 97%RA.
Laboratories significant for lactate 5.9, WBC 11.9. Code sepsis
was subsequently called, and she was given CTX 2gm IV, Levaquin
500 mg IV, and tylenol. The patient's temperature decreased and
her lactate decreased to 3.5. Chest CT was obtained to further
evaluate possible infectious etiolgies and incidentally noted
large bilateral pulmonary emboli. Given altered mental status,
head CT obtained, which is unchanged from prior. A left
subclavian was placed, but then noted to be kinked and
ultimately pulled.
.
An IVC filter was placed after the findings of pulmonary
embolism as anticoagulation is not an option given her cancer
metastatic to brain.
.
The patient was initially treated with ceftriaxone and
levofloxacin but as there was no source of infection found
antibiotics were discontinued. The patient was initially noted
to have SBP 80-90s but blood pressure improved with fluid
boluses. The patient continues to complain of right leg weakness
and word-finding difficulties which she says are new over
two-three days. She denies pain. She denies shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea, melena,
hematochezia, dysuria, hematuria, oral lesions.
Past Medical History:
ONCOLOGIC HISTORY:
In [**2126**], Ms. [**Known lastname **] was diagnosed with a 0.577 mm [**Doctor Last Name 10834**] level 4
melanoma of the right shoulder. She underwent wide local
excision and remained clinically asymptomatic for 7 years. In
[**12/2133**], she developed right axillary node lymphadenopathy.
Biopsy was consistent with melanoma. She underwent right
axillary lymph node dissection in 02/[**2133**]. Her followup CT
showed liver metastasis. She began high-dose IL-2 in 6/[**2133**]. Her
followup CT scan showed interval increase in size of the right
liver mass as well as interval increase in size of multiple
renal lesions and a new peritoneal or omental nodularity
consistent with metastatic disease. Additionally, she was found
to have an increase in her pancreatic mass. She subsequently
underwent a staging MRI of the brain prior to initiation of the
new treatment protocol. The MRI on [**2134-6-6**] revealed a small
focal areas of metastatic involvement in both temporal lobes and
possibly in the left mamillary body. One lesion in the anterior
left temporal lobe region was reported to be probably consistent
with meningeal disease. At that time, the patient was
asymptomatic from her neurologic disease. She was referred to
neurooncology, who treated her with 3600 [**Doctor Last Name 352**] of radiation.
Followup MRI revealed progression of one of her brain lesions. A
CT scan on [**2134-8-9**] showed a massive increase in the metastatic
disease burden with metastasis to the liver, pancreas, and
subcutaneous tissues and massive increase in the amount of
intra-abdominal, intrapelvic lymphadenopathy as well as omental
nodularity. She was started on temozolomide at 300 mg daily on
[**2134-8-31**]. She took the medication [**2134-8-31**] to [**2134-9-5**].
.
PAST MEDICAL/SURGICAL HISTORY: She had eye surgery in OD and
cataract surgery in OU (all at the [**Hospital3 2358**]).
Social History:
She does not smoke cigarettes. She drinks [**11-30**] glasses of wine
per night.
Family History:
Her mother had skin cancer. Her father died of stroke and had
hypertension. Her brother is healthy while her sister has breast
cancer. She does not have any biological children but she has an
adopted daughter.
Physical Exam:
VITAL SIGNS: 96.1 105 113/71 18 98%RA
GENERAL: Speaks very slowly, flat affect
HEENT: PERRL, EOMI, visual field decreased laterally
bilaterally, MMM
HEART: RRR, no M/R/G
CHEST: CTAB
ABDOMEN: NABS, soft, NTND
EXTREMITIES: Warm, well perfused
NEUROLOGIC: AAOx3, CN II-XII intact; sensation to light touch
intact; strength 4/5 throughout, symmetric; patellar and
brachoradialis reflexes intact; patient with word-finding
difficulties, cannot spell "world" backwards; gait narrow-based
and shuffling
Pertinent Results:
Labwork on admission:
[**2134-10-7**] 12:30PM WBC-11.9* RBC-4.29 HGB-15.0 HCT-40.5 MCV-95
MCH-34.9* MCHC-36.9* RDW-14.7
[**2134-10-7**] 12:30PM PLT COUNT-437
[**2134-10-7**] 12:30PM NEUTS-87.8* LYMPHS-8.2* MONOS-3.7 EOS-0.2
BASOS-0.1
[**2134-10-7**] 12:30PM GRAN CT-[**Numeric Identifier 30005**]*
[**2134-10-7**] 12:30PM GLUCOSE-119* UREA N-9 CREAT-0.5 SODIUM-138
POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-25 ANION GAP-20
[**2134-10-7**] 12:30PM ALBUMIN-4.1 CALCIUM-9.8 PHOSPHATE-3.6
MAGNESIUM-2.3
[**2134-10-7**] 12:30PM ALT(SGPT)-14 AST(SGOT)-13 ALK PHOS-54 TOT
BILI-0.4
[**2134-10-7**] 12:30PM LIPASE-39
[**2134-10-7**] 12:30PM CORTISOL-29.3*
[**2134-10-7**] 12:30PM CRP-3.6
[**2134-10-7**] 12:47PM LACTATE-5.9*
[**2134-10-7**] 02:30PM PT-11.2 PTT-24.1 INR(PT)-0.9
[**2134-10-7**] 04:00PM LACTATE-3.5*
[**2134-10-7**] 04:01PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2134-10-7**] 04:01PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2134-10-7**] 04:01PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-<1
.
CT CHEST/ABDOMEN/PELVIS W/CONTRAST [**2134-10-7**]
IMPRESSION:
1. Extensive bilateral pulmonary emboli extending from the main
pulmonary arteries bilaterally into the lower lobar branches and
subsegmental branches. This is new in comparison to the prior
study. There are several filling defects within the right atrial
appendage. This appears adjacent to a nodule along the
pericardium, and is concerning for thrombus in this location,
possibly of a metastatic origin.
2. Extensive diffuse metastatic disease within the mediastinum,
soft tissues, liver, pancreas, and omentum. These have increased
in size and number in comparison to the prior study. New lytic
lesion in the L1 vertebral body concerning for a new osseous
metastasis.
3. Left apical pneumothorax, as seen on the recent chest
radiograph.
.
CT HEAD W/ & W/O CONTRAST [**2134-10-7**]
IMPRESSION: No hemorrhage or herniation. Of the multiple
previously described lesions, only the lesion at the left
mamillary body is identified on the current study. This is
likely due to differences in the sensitivities between MRI and
CT. No definite new lesions are identified.
.
ECHO Study Date of [**2134-10-8**]
Conclusions:
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. No
aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is no pericardial effusion.
IMPRESSION: No echo evidence of RV strain.
.
WBC, CSF 9 #/uL
CLEAR AND COLORLESS
RBC, CSF 9* #/uL 0 - 0
Polys 0 %
Lymphs 97 %
Monocytes 3 %
.
Labwork on discharge:
[**2134-10-15**] 07:05AM BLOOD WBC-10.1 RBC-3.61* Hgb-11.9* Hct-35.2*
MCV-98 MCH-33.1* MCHC-33.9 RDW-15.1 Plt Ct-507*
[**2134-10-15**] 07:05AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-136
K-4.4 Cl-92* HCO3-29 AnGap-19
Brief Hospital Course:
62 year-old woman with metastatic melanoma now admitted for
fever and weakness and found to have bilateral pulmonary emboli.
.
1. Pulmonary embolus. Her metastatic cancer puts her at risk for
thromboembolic disease. It is unclear the increased risk of [**Name (NI) 11011**]
with the specific therapies that she has received. It is
possible that the majority of the presenting constellation of
findings could be explained by pulmonary emboli, such as fever,
lactic acidosis, and hypoxia. The patient is status post IVC
filter placement from the ED by IR; the patient is not a
candidate for anticoagulation given brain metastases.
Echocardiogram showed no evidence of right heart strain as
above. The patient did not require supplemental oxygen.
.
2. Mental status changes/expressive aphasia. Oriented x 3 but
with neurologic deficits of word-finding and attention; these
were improving prior to discharge. Unclear etiology. Possible
etiologies leptomeningeal spread, seizure, metabolic
abnormalities, chemotherapy, or other drug-induced. No evidence
of new or worsening metastases or infarction on MRI head [**10-10**].
No evidence of infection. The patient had evidence of
leptomeningeal disease in [**6-3**] but is now status post WBI. The
patient had a lumbar puncture performed to rule out recurrent
leptomeningeal disease. Cytology was preliminarily negative but
the formal [**Location (un) 1131**] was pending on discharge. CSF cultures remain
negative at the time of discharge. The patient was started on
sinemet for question Parkinson's disease per neuro/oncology
recommendations with good effect.
.
3. Weakness. She has complaints of generalized weakness over the
past several days, which per her sister, is a marked change.
While there is no definite finding on exam, it is unclear if
these findings could be related to her cancer, the treatment, or
metabolic derangements. The patient had a shuffling gait on
exam. The patient was followed by her neuro-oncologist during
admission. The patient's decadron was increased to 4 mg IV twice
daily. Lumbar puncture was performed to rule out leptomeningeal
disease and the preliminary cytology was negative. The patient
was started on Sinemet for Parkinson's-like symptoms with good
effect. The patient was followed by physical therapy throughout
admission. She was started on a decadron taper on discharge.
.
4. Parkinson's-like symptoms. The patient was followed by her
neuro-oncologist during admission. The patient's mask-like
facies and shuffling gait were believed to be secondary to
Parkinson's disease. The patient was started on Sinemet with
good effect.
.
5. Metastatic melanoma. The patient completed cycle 2 of
temozolomide prior to admission. The patient was followed by her
oncologist during admission. The patient's cell counts remained
stable throughout hospitalization. The patient will follow-up
with her oncologist and neuro-oncologist regarding further
treatment.
.
6. Fever/Sepsis/Lactic acidosis. There was initially concern for
SIRS/sepsis given the presentation of fever, hypoxia, and
perceived confusion shortly after completing chemotherapy. It is
possible that the majority of the presenting constellation of
findings could be explained by large pulmonary emboli, such as
fever, lactic acidosis, hypoxia. The patient was initially
treated with antibiotics but these were discontinued when the
patient was afebrile and with negative cultures for 72 hours.
The patient's blood cultures were negative at the time of
discharge. Lumbar puncture was performed as above and cultures
were negative at the time of discharge.
.
7. Depression. The patient's celexa was initially held with the
patient's change in mental status but was restarted during
hospitalization without ill effect.
.
FEN: Regular diet, replete lytes prn
PPX: PPI, IVC filter, eating, bowel regimen prn
Code: Full
Comm: Sister is HCP
Medications on Admission:
MEDICATIONS:
Celexa 40 mg QD
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Please take while taking steroids.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day:
Please taper as follows starting [**2134-10-16**]:
- 4 mg QAM and 2mg QPM for three days
- 2 mg QAm and 2 mg QPM for three days
- 2 mg QAM for three days
- Discontinue steroids.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1514**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Center
Discharge Diagnosis:
Primary:
1. Pulmonary embolus, status post IVC filter placement
2. Parkinson's-like symptoms, on Sinemet
3. Metastatic melanoma
.
Secondary:
Eye surgery OD adn cataract surgery OU
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
Please contact a physician if you experience fevers, chills,
headache, increased weakness, or any other concerning symptoms.
.
Please take your medications as prescribed.
- You have been started on Sinemet for Parkinson's-like
symptoms.
- Your decadron will be tapered as follows starting tomorrow:
--4 mg QAM, 2 mg QPM for 3 days
--2 mg [**Hospital1 **] for 3 days
--2 mg QAM for 3 days
--Discontinue steroids
- Please continue protonix while taking steroids.
.
Please call the office of your oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**],
at([**2134**] to schedule an appointment.
Followup Instructions:
You have a follow-up appointment with your oncologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**] on Tuesday, [**10-26**] at 3:30pm. Please call
([**2134**] with any questions or concerns.
.
Please call the office of your neuro-oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**],
at ([**Telephone/Fax (1) 6574**] to schedule an appointment.
Completed by:[**2134-10-15**]
|
[
"198.3",
"V10.82",
"197.8",
"197.7",
"332.0",
"415.19",
"197.6",
"197.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
12853, 12977
|
7961, 11839
|
358, 381
|
13201, 13233
|
4938, 4946
|
13904, 14342
|
4196, 4407
|
11918, 12830
|
12998, 13180
|
11865, 11895
|
13257, 13881
|
4422, 4919
|
7721, 7938
|
277, 320
|
409, 2149
|
4960, 7707
|
2171, 4082
|
4098, 4180
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,372
| 196,154
|
11475
|
Discharge summary
|
report
|
Admission Date: [**2193-9-11**] Discharge Date: [**2193-9-26**]
Date of Birth: [**2135-10-8**] Sex: M
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
gentleman transferred from [**Hospital3 **] with subarachnoid
hemorrhage and intraventricular hemorrhage. The patient has
a past medical history of etoh abuse and tracheostomy for
[**Hospital3 766**] night, 10-22 times two, witnessed by his wife, brought
to the local Emergency Room where patient was confused. At
baseline patient is ambulatory. In the Emergency Room the
patient noticed to be coughing up thick yellow sputum,
growing staph aureus. Head CT revealed an intraventricular
hemorrhage and subarachnoid hemorrhage. The patient
transferred to [**Hospital1 69**] for
complained of severe headache on [**Name (NI) 766**], unclear if headache
preceded the fall, but has since developed a right sided
weakness. The patient was also drinking at the time of the
fall.
PAST MEDICAL HISTORY: Tracheostomy for a laryngeal
carcinoma, peptic ulcer disease, arthritis, etoh.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Prilosec, Cytotec, Vioxx.
LABORATORY DATA: Chest x-ray negative by report. Admitted
to [**Hospital3 **] with diagnosis of bronchitis and started
on Levaquin.
PHYSICAL EXAMINATION: Temperature 98.6, blood pressure
150/80, respiratory rate 12. In general no acute distress.
HEENT: Anicteric, left ptosis. Neck tender, stiffness with
decreased range of motion. Chest. wheezing bilaterally.
Cardiac, regular rate and rhythm. No murmur, rub or gallop.
Extremities warm, dry, no clubbing, cyanosis or edema.
Neuro, awake, alert, attentive. GCS 15, oriented times
three, speech labored secondary to trach. Pupils 3 to 2
bilaterally and brisk. Extraocular movements intact. No
nystagmus. Finger to nose, visual fields full to
confrontation, face symmetric, left ptosis. Tongue palate
symmetric, positive corneals bilaterally, face symmetric.
Motor strength on the left, deltoid 4, biceps 3, triceps 3,
grip 4, IP 4, ATs 4, [**Last Name (un) 938**] and gastroc 4. On the right,
deltoids 3, biceps 4, triceps 4, grasp 4, IP looked like he
is plegic, unable to move the right lower extremity. CT
shows large blood clot at the body of the corpus callosum
pressing down into the body of the lateral ventricle.
LABORATORY DATA: On admission, white count 9.5, hematocrit
38.4, platelet count 75,000, sodium 141, potassium 3.3,
chloride 105, CO2 24, BUN 15, creatinine .7, glucose 98, INR
1.12.
HOSPITAL COURSE: The patient was admitted to the surgical
Intensive Care Unit. On further questioning of the family,
the patient is found to be a heavy alcohol abuser. The patient
falls frequently. On [**Last Name (un) 766**] he fell in the kitchen, hit his
head, had positive loss of consciousness for 10 minutes.
When he woke up he acted appropriately, went to bed and then
next morning his wife came home at 11 a.m. and found him on
the couch lethargic and that is when EMS was called. He also
has a past medical history of a detached retina on the left.
The patient went for an angiogram which was negative for any
aneurysm or vascular malformation. The patient also had CTA,
MRA, MRI of the brain to rule out some kind of underlying
lesion under the blood clot which was essentially negative,
just showed a hematoma with no underlying lesions. The
patient has spiked a temperature and is currently being
treated for MRSA pneumonia. The patient had a full 10 day
course of Levaquin 500 mg IV for staph aureus in his sputum
on admission and currently now is positive for MRSA in his
sputum. The patient also has aspiration from his trach. He
had a swallow study which showed he was aspirating and had
PEG placement. The patient was transferred to the floor on
hospital day #3.
DISCHARGE MEDICATIONS: Protonix 40 mg po q day, Lisinopril
30 mg per PEG q day, Dilantin 100 mg per PEG q 8 hours,
Percocet 1-2 tabs per PEG q 4 hours prn, Tylenol 650 mg per
PEG q 4 hours prn, Thiamine 100 mg per PEG q day, Folate 1 mg
per PEG q day, MVI one per PEG q day, Protonix was
discontinued. The patient is on Prevacid suspension 30 mg
per PEG q 24 hours.
The patient is in stable condition and ready for transfer to
rehab. He will require a follow-up with Dr. [**Last Name (STitle) 1132**] in one
months time. He was in stable condition at the time of
discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2193-9-25**] 11:38
T: [**2193-9-25**] 12:34
JOB#: [**Job Number 5382**]
|
[
"374.31",
"303.90",
"276.1",
"342.90",
"V55.0",
"430",
"V10.21",
"482.41",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.55",
"88.41",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
3845, 4658
|
2547, 3821
|
1313, 2529
|
151, 959
|
982, 1290
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,611
| 141,205
|
46609
|
Discharge summary
|
report
|
Admission Date: [**2140-5-5**] Discharge Date: [**2140-5-10**]
Date of Birth: [**2073-5-10**] Sex: F
Service: SURGERY
Allergies:
Morphine / Codeine / Bactrim / Zestril
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
esrd on hemodialysis with side effect of hypotension
Major Surgical or Invasive Procedure:
[**2140-5-5**] laparoscopy with lysis of adhesions
History of Present Illness:
Per Dr.[**Initials (NamePattern4) 8584**] [**Last Name (NamePattern4) **] note as follows:
66-year-old woman who is currently maintained on hemodialysis
through a right upper arm AV graft. She does not tolerate
dialysis well with
periods of hypotension. She wishes to be considered for a
peritoneal dialysis catheter placement. She has had multiple
prior abdominal and pelvic surgeries.
Past Medical History:
1. Stage V chronic kidney disease: Estimated GFR of 9,
creatinine 5.3.
2. Insulin-dependent diabetes complicated by retinopathy,
neuropathy, and nephropathy.
3. Diastolic CHF, most recent EF 50% by echo.
4. Hypertension.
5. Obstructive sleep apnea, on CPAP.
6. Pulmonary hypertension.
7. Dyslipidemia.
8. Hypothyroidism.
9. Benign polymyalgia rheumatica, on chronic low-dose
prednisone.
10. Fibromyalgia.
11. Chronic back pain.
12. GERD.
13. Depression.
Social History:
Closest relative is brother who lives in [**Location (un) 55**]. She is a
former secretary. She quit tobacco 12 years ago, with 40+
pack-year history. Denies etoh and illicit drug use, states she
used to drink alcohol and also quit 12 years ago
Family History:
Father had CAD, died of GBM. Mother had esophageal and skin
cancer, died of an "ascending aneurysm." Brother with prostate
cancer. Several family members with diabetes.
Physical Exam:
see [**Location (un) **] notes
Pertinent Results:
[**2140-5-6**] 05:55AM BLOOD WBC-10.5 RBC-3.24* Hgb-10.6* Hct-33.8*
MCV-104* MCH-32.8* MCHC-31.5 RDW-14.1 Plt Ct-290
[**2140-5-7**] 04:58AM BLOOD WBC-16.1*# RBC-3.36* Hgb-11.1* Hct-35.0*
MCV-104* MCH-32.9* MCHC-31.6 RDW-14.1 Plt Ct-242
[**2140-5-9**] 05:20AM BLOOD WBC-9.1 RBC-3.16* Hgb-10.3* Hct-32.5*
MCV-103* MCH-32.7* MCHC-31.8 RDW-14.1 Plt Ct-265
[**2140-5-9**] 05:20AM BLOOD PT-10.6 PTT-26.1 INR(PT)-1.0
[**2140-5-6**] 05:55AM BLOOD Glucose-128* UreaN-59* Creat-6.3* Na-138
K-6.1* Cl-101 HCO3-26 AnGap-17
[**2140-5-9**] 05:20AM BLOOD Glucose-183* UreaN-77* Creat-8.8*#
Na-130* K-4.6 Cl-85* HCO3-25 AnGap-25*
[**2140-5-7**] 08:58AM BLOOD ALT-7 AST-39 LD(LDH)-289* CK(CPK)-226*
AlkPhos-164* TotBili-0.2
[**2140-5-9**] 05:20AM BLOOD ALT-3 AST-46* AlkPhos-185* TotBili-0.3
Time Taken Not Noted Log-In Date/Time: [**2140-5-6**] 8:29 pm
MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2140-5-8**]**
MRSA SCREEN (Final [**2140-5-8**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2140-5-6**] 8:08 pm SWAB Source: Rectal swab.
**FINAL REPORT [**2140-5-8**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2140-5-8**]):
No VRE isolated.
[**2140-5-6**] 3:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
[**2140-5-5**] Attempted placement of peritoneal dialysis catheter
with exploratory laparoscopy. PD cath was attempted for
hypotension during hemodialysis sessions. PD catheter placement
was unsuccessful due to bleeding and adhesions. Lysis of
adhesions was done. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to
operative notes for details. She was sleepy postop with stable
vital signs.
Postop day 1, she was dialyzed via the RUE AVG. She became
somnolent with low grade temperature and O2 desaturation to 80s.
CXR showed mild vascular congestion/fluid overload. Given desat
and mental status, she was sent to the SICU for urgent
hemodialysis. Troponins were sent and were negative. Blood
cultures were also sent. Chest CTA was done to r/o PE. This was
negative. Hemodialysis was performed for volume overload with 2
liters removed.
On postop day 2, CXR again appeared wet and hemodialysis was
again performed for 2 liters of fluid removed. CXR also
demonstrated vascular congestion with atelectasis (left greater
than right side). On [**5-8**], CXR demonstrated pulmonary edema and
opacification at the right base with poor definition of the
hemidiaphragm consistent with atelectasis and effusion. There
was concern for aspiration pneumonia give elevation in WBC to
16, alteration in mental status and CXR. Ceftriaxone and
Azithromycin were started on [**5-7**].
Vital signs and mental status improved. Blood cultures were un
finalized, but negative to date. Hemodialysis was done again on
[**Month/Year (2) 766**] [**5-9**], removing 1.8 liters. She continued to wear her
CPAP. Diet was advanced and tolerated. Abdominal incisions were
intact and without redness or drainage.
PT assessed her and recommended rehab. She remained afebrile
with stable vital signs. The plan was to continue just the
Azithromycin for 1 week from discharge.
She will transfer to [**Hospital1 599**] [**Location (un) 55**] rehab with plan to go
to [**Location (un) **] Dialysis in [**Hospital1 8**]
[**Location (un) 96522**] # 1
[**Hospital1 8**]
([**Telephone/Fax (1) 98981**]
on [**Telephone/Fax (1) 766**]-Wednesday-Friday schedule. Hemodialysis will be at
11am on [**5-11**]. She should continue to be on a 750ml fluid
restriction.
Medications on Admission:
Renal cap qd, carvedilol 12.5mg [**Hospital1 **], clobetasol 0.05%tp to rash
on shins [**Hospital1 **] prn, cymbalta 90mg qd, lantus 24 units hs, humalog
ss, lactulose prn constipation, levothyroxine 88mcgqd,
prednisone 3mg qd, crestor 40mg qd, sevelamer carbonate 2400mg
tid/snacks, vit c 500mg', colace 200mg hs, senna prn
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): to rash on shins .
4. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. insulin glargine 100 unit/mL Solution Sig: Twenty Four (24)
units Subcutaneous at bedtime.
11. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day.
12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: no more than 2600mg per day.
14. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
15. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
16. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
17. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
Six (26) units Subcutaneous once a day: am.
18. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
19. prednisone 1 mg Tablet Sig: Three (3) Tablet PO once a day:
PMR.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
ESRD
Abdominal adhesions, bleeding from adhesions intraop
DM
Fluid volume overload/respiratory distress
Right lobe pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
temperature of 101 or greater, chills, nausea, vomiting,
increased abdominal pain/distension, incision
redness/bleeding/drainage or malfunction of AV graft
-resume usual hemodialysis
-you may shower with soap and water. do not put powder/ointment
on incisions
Avoid lifting anything heavier than 10 pounds. No straining
No driving while taking pain medication
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-5-19**] 3:45
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2140-5-30**]
1:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2140-6-6**]
3:00
Completed by:[**2140-5-10**]
|
[
"583.81",
"V64.1",
"E878.8",
"278.00",
"507.0",
"250.40",
"V58.67",
"327.23",
"428.33",
"998.11",
"428.0",
"568.0",
"585.6",
"V45.11",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"54.51"
] |
icd9pcs
|
[
[
[]
]
] |
7578, 7668
|
3180, 5455
|
350, 403
|
7837, 7837
|
1829, 3120
|
8477, 8950
|
1593, 1763
|
5830, 7555
|
7689, 7816
|
5481, 5807
|
7988, 8454
|
1778, 1810
|
3156, 3156
|
258, 312
|
431, 822
|
7852, 7964
|
844, 1314
|
1330, 1577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,314
| 148,553
|
44966
|
Discharge summary
|
report
|
Admission Date: [**2199-5-26**] Discharge Date: [**2199-5-30**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 74 [**Hospital **] nursing
home resident with a past medical history of type 2 diabetes
mellitus, depression, dementia, psychosis who presented to
[**Hospital1 69**] on [**2199-5-26**] from
[**Hospital **] with lethargy, diaphoresis and
slurred speech of unclear duration. The patient was alert
and oriented to herself, but very somnolent. On admission
her white blood cell count was 22 with 89% neutrophils. She
had a urinalysis, which was positive and her sodium was found
to be 124 and her BUN and creatinine were up to 117 and 3.4
respectively from a baseline of 0.8 in [**2197**]. The patient had
a chest x-ray and renal ultrasound done on admission, which
were negative. The patient was started on Levaquin for her
urinary tract infection and due to her hypernatremia she was
sent to the Intensive Care Unit. The etiology of the
hypernatremia is thought to be secondary to her standing
doses of Lasix in the setting of poor po intake. The
patient's free water deficit was calculated at 9 liters and
the patient's sodium was corrected by 10 milliequivalents of
sodium a day. The patient's sodium slowly trended down and
as her sodium decreased her mental status significantly
improved. Her acute renal failure was prerenal in etiology
and also improved with intravenous fluid hydration.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. Major depression.
4. Osteoarthritis.
5. Dementia.
6. Anxiety.
7. Dementia.
8. Internal hemorrhoids.
9. Psychosis.
MEDICATIONS AT HOME:
1. Lasix 20 a day.
2. Glyburide.
3. Senna.
4. Lexapro 20 a day.
5. Seroquel 50 mg q.a.m. and 100 mg q.h.s.
6. Protonix 40 mg q.d.
7. Lisinopril 10 a day.
8. Aricept 10 a day.
9. Ativan 0.5 q.h.s. prn.
10. Lopresor 12.5 b.i.d. prn.
11. Sliding scale insulin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She had no history of tobacco or alcohol
use.
FAMILY HISTORY: Not available.
PHYSICAL EXAMINATION ON ADMISSION TO THE INTENSIVE CARE UNIT:
temperature 98.5. Blood pressure 120/44. Heart rate of 60.
Respiratory rate 20. She was 97% no 2 liters nasal cannula.
In general, she was resting quietly, but was somnolent and
alert and oriented times one. HEENT mucous membranes are
dry. Cardiovascular regular rate and rhythm. She had 1 out
of 6 systolic murmur. Lungs were clear to auscultation
bilaterally. Abdomen was soft, obese, nontender,
nondistended. Extremities she had trace lower extremity
edema.
LABORATORY: As noted above.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit.
1. Hypernatremia: The hypernatremia was in the setting of
acute renal failure and urinary tract infection. The acute
renal failure was likely due to dehydration as noted above.
Her free water deficit was corrected. Her sodium improved
and as her sodium came down her mental status improved. Her
sodium on the day of discharge is 145.
2. Mental status changes: Likely secondary to
hypernatremia. Her mental status improved likely to her
baseline.
3. Urinary tract infection: The patient was started on her
Levaquin for her urinary tract infection. Her urine culture
grew out gram negative rods, which were resistant to
Levaquin. She has been started on Ceftriaxone. She will need
one dose of IM Ceftriaxone on the day after discharge to
complete the course of antibiotics.
4. Renal: The acute renal failure as noted above improved
with rehydration.
5. Cardiovascular: The patient's blood pressure was well
controlled at this time, but given her acute renal failure
her ace inhibitor was held. She will be continued on her
beta-blocker as per her normal dose.
6. Endocrine: The patient was continued on sliding scale
insulin as needed.
7. The patient was seen by the Speech and Swallow Service
for evaluation of her swallow. They felt that the patient
should continue to have a diet of nectar thick liquids and
pureed consistency. She should be seated upright for all
meals. She should be supervised during her meals with
minimized distractions and her medications should be crushed
and nectar.
DISCHARGE STATUS: The patient will be discharged back to
[**Hospital3 **] home when a bed becomes available.
DISCHARGE MEDICATIONS:
1. Lexapro 20 q.d.
2. Seroquel 100 mg po q.h.s.
3. _______________ 10 mg po q.h.s.
4. Seroquel 50 mg po q.a.m.
5. Protonix 40 mg po q.d.
6. Ceftriaxone 1 gram IM to be given once on [**5-31**].
7. Her ace inhibitor and Lasix should be discontinued at
this time and not to be restarted until restarted by her
doctor. Her blood pressure was controlled off the
beta-blocker as well so the beta-blocker had been
discontinued.
DISCHARGE INSTRUCTIONS: Please follow up with your primary
care physician in the next one to two weeks and have blood
drawn and follow creatinine.
DR.[**Last Name (STitle) 4174**],[**First Name3 (LF) **] 12-925
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2199-5-30**] 11:15
T: [**2199-5-30**] 12:10
JOB#: [**Job Number 96151**]
|
[
"041.85",
"300.00",
"250.00",
"599.0",
"296.20",
"401.9",
"780.99",
"584.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2040, 2619
|
4348, 4779
|
2637, 4325
|
4804, 5148
|
1651, 1959
|
123, 1435
|
1457, 1630
|
1976, 2023
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,449
| 164,791
|
33930
|
Discharge summary
|
report
|
Admission Date: [**2160-8-27**] Discharge Date: [**2160-9-1**]
Date of Birth: [**2086-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coranry artery disease
mitral regurgiation
Major Surgical or Invasive Procedure:
Coronary Artery bypass grafts x 4 (LIMA-LAD,
SVG-DG,SVG-OM,SVG-PDA), Mitral Valve Repair (28mm [**Company 1543**] CG-3
Ring)
History of Present Illness:
Exertional angina in setting of known coronary artery disease.
Past Medical History:
Resection of meningioma
Chronic Sinusitis
Hypertension
gastroesophageal reflux
h/o Bladder cancer
hyperlididemia
depression
s/p coronary stenting
Social History:
Social history is significant for the absence of current tobacco
use. There is social history of alcohol use. Baseline active.
Family History:
There is family history of premature coronary artery disease
(father, age unknown).
Physical Exam:
Awake, alert and oriented.
VSS, afebrile
Lungs- clear
cor- SR. crisp heart sounds
exts- trace edema
wounds- clean and dry. healing well, sternum stable.
Pertinent Results:
[**2160-8-31**] 05:15AM BLOOD WBC-7.7 RBC-2.98* Hgb-9.6* Hct-26.6*
MCV-89 MCH-32.0 MCHC-35.9* RDW-15.2 Plt Ct-176
[**2160-9-1**] 05:25AM BLOOD PT-15.2* INR(PT)-1.3*
[**2160-8-31**] 08:50AM BLOOD PT-13.0 INR(PT)-1.1
[**2160-8-28**] 08:15PM BLOOD PT-13.6* PTT-33.3 INR(PT)-1.2*
[**2160-8-27**] 02:11PM BLOOD PT-16.8* PTT-39.0* INR(PT)-1.5*
[**9-1**]/Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.6 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Findings
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: Normal LV wall thickness and cavity size. Normal
LV wall thickness. Normal LV cavity size. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Torn mitral chordae. Moderate (2+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**12-5**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2. 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%).
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Torn mitral
chordae are present. Moderate (2+) mitral regurgitation is seen.
7.There is no pericardial effusion.
8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2160-8-27**]
at 1030 am.
POSTBYPASS
1. Patient is on phenylephrine infusion and AV paced.
2. Left ventricular ejection fraction is 55%, no wall motion
abnormalities
3. A mitral annuloplasty ring has been placed. No mitral
regurgitation is seen. Mean gradient 2.1 mmHg, MVA 2.24. Chordal
[**Male First Name (un) **] with no LVOT obstruction present.
4. Aortic contour smooth after decanulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician
?????? [**2154**] CareGroup IS. All rights reserved.
08 05:25AM BLOOD Creat-0.7 K-4.6
Brief Hospital Course:
Mr. [**Known lastname **] was admitted for elective cardiac catheterization
due to recurrent exertional angina in the face of known right
disease, s/p stenting twice. This revealed 40-50% LAD and
circumflex disease, occlusive disease of the obtuse marginal
proximaly and diffuse right disease with stenosis of the
proximal stent. LV function was intact at 60% with trivial
MR/TR.
He was admitted for elective surgery. On [**8-27**] coronary bypass
grafting x 4 was performed, along with mitral annuloplasty.
Neosynephrine was necessary to wean from cardiopulmonary bypass.
He remained stable, awoke intact and was extubated th eday of
surgery. Pressors were necessary for the first 24 hours and
after atrial pacing and blood transfusion, this was weaned off
on the second postoperative day.
He was transferred to the floor. Analgesics controlled his pain
adequately and he was hemodynamically stable and ready for
discharge. He was ambulatory with the aid of a walker due to an
unsteady gait. He is being transferred to a rehabilitation
facility for recovery and physical therapy prior to his return
home.
Medications on Admission:
Lisinopril 5mg/D,VitC 500mg/D, Leveitiracetam 250mgAM/750PM,
Lipitor 80mg/D, Prozac 40g/D, Fluticasone spray/D, Tamulosin
0.4mg/D, Metoprolol 12.5mgBID,Nexium 40mg/D, ASA 325mg/D,Detrol
LA4mg/D,Imdur 60mg/D, vitamens
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(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. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*1 1* Refills:*2*
9. 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*
10. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily) as needed for AFIB: INR 2.5-3.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Sachem Skilled Nursing & Rehabilitation - [**Location 21318**]
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafts x 4, mitral valve replacement
s/p coronary stenting x2
Hyperlipidemia
s/p resection of meningioma
benign prostatic hypertrophy
gastroesophageal reflux
h/o bladder cancer
chronic sinusitis
depression
Discharge Condition:
good
Discharge Instructions:
No lifting more than 10 pound for 10 weeks
No driving for 4 weeks and off all narcotics
Shower daily, no baths or swimming
No lotions, creams or powders to incisions
Report any redness of,or drainage form incisions
Report any temperature greater than 100.5
Report any weight gain of more than 2 pounds in a day or 5
pounds in a week
Take all medications as prescribed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 20561**] in [**1-6**] weeks
Dr. [**Last Name (STitle) 7047**] in [**1-6**] weeks
Completed by:[**2160-9-1**]
|
[
"458.29",
"473.9",
"311",
"996.72",
"412",
"600.00",
"V10.51",
"V04.81",
"272.4",
"413.9",
"V45.82",
"530.81",
"427.31",
"424.0",
"V12.41",
"401.9",
"E878.1",
"414.01",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"99.04",
"36.13",
"39.61",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
7515, 7604
|
4903, 6017
|
363, 490
|
7905, 7912
|
1187, 4880
|
8329, 8537
|
914, 999
|
6284, 7492
|
7625, 7884
|
6043, 6261
|
7936, 8306
|
1014, 1168
|
281, 325
|
518, 582
|
604, 752
|
768, 898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,845
| 116,809
|
49923
|
Discharge summary
|
report
|
Admission Date: [**2130-3-31**] Discharge Date: [**2130-4-11**]
Date of Birth: [**2052-7-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors /
Angiotensin Recp Antg&Calcium Chanl Blkr / Meloxicam
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
Transfusions with packed red blood cells and fresh frozen plasma
History of Present Illness:
77 yo female with HTN, DM, CRI, on prednisone for RA, open
laparotomy for perforated dudenal ulcer at [**Hospital3 **] on
[**2130-3-10**], and recently hosp from [**Date range (1) 104274**] for high INR who was
sent to the ED from [**Hospital3 **] for high INR and HCT of 16.9.
She was seen in ED on [**2130-3-29**] and found to have UTI yeast >
100,000. She was started on ciprofloxacin 500mh [**Hospital1 **] on [**3-29**].
Per [**Hospital3 **] she has had no bloody/black stool or bleeding
from her coccyx wound site. She has had no n/v. She has
received 2.5mg po vit K on [**2130-3-29**]. WBC today at [**Hospital3 **]
was 11. Given increasing creatinine they were holding lasix on
[**2-24**], and [**3-31**] and giving 500ml po TID. VS prior to
transfer to [**Hospital1 **] were 97/64 P103 100% RA.
.
In the ED, initial vs were T95.6 P98 (HR 77-92) BP108/77
(103-115/54-68) R22 (18-28) O2 sat 100%. In the ED HCT was noted
to be 16.9 (HCT 25.7 2 days ago). INR was 5.3. Patient was
given 10mg po vit K and 1.5 units of blood. She was guaiac
negative and NG lavage was not done given high INR and no
evidence of GI bleed. She reported back pain and CT abd was
negative for RP bleed. Initially only had 25cc of pus looking
UOP. She received 80mg IV lasix and had made 250cc of urine by
the time she arrived to the floor. Her urine cx from [**2130-3-29**]
grew >100,000 yeast. Her UA from today had >50 WBC, moderate
bacteria, and [**12-24**] WBC. She was given IV ceftriaxone. Her lung
exam was notable for crackles at the bases. She was difficult
to obtain access on and a right IJ was placed. Max HR in the ED
was 92 and lowest BP was 103. Vitals prior to transfer were T98
HR 78 BP 124/68 RR18 100% on 2L. CXR showed small bilateral
pleural effusions.
.
On the floor, pt reports [**11-13**] back pain worse this AM than
previously. However, she has been having the back pain since
earlier this month after her abdominal surgery.
.
Review of systems:
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
#. Left deep venous thrombosis involving the internal jugular
and brachial veins [**2-14**] on coumadin
#. Hypertension - TTE [**3-14**] - EF >55%. Mild AR
#. DM2 - diagnosed [**2118**], has been on insulin in the past but no
longer takes any diabetes medications
#. CKD - baseline creatinine 3.0
#. Rheumatoid arthritis - diagnosed at age 50; [**Doctor First Name **] 1:1280 -
followed by Dr. [**Last Name (STitle) 6426**]; on chronic steroids
#. Hypothyroidism
#. Osteoarthritis
#. Possible SLE, discoid lupus since [**2121**] with a positive right
sided lymph node biopsy
#. Left renal mass detected in [**2121-8-4**] - pt doesn't want
further w/u
#. Anemia - Normocytic in past
#. Asthma
#. History of low back pain
#. C. diff colitis with recurrence 8 and [**10-9**]
#. ?Cecal Mass on CT - [**Last Name (un) **] [**6-10**] negative. CEA 5.7
#. L renal mass
#. ?Coronary atherosclerosis
#. h/o PNA
#. Dysphagia
#. UTIs- multiple recent UTIs + for yeast
.
Allergies:
Ace Inhibitors
Angiotensin Recp Antg&Calcium Chanl Blkr
Meloxicam
Penicillins
Sulfa (Sulfonamide Antibiotics)
Social History:
.
Social History:
Drugs: None
Tobacco: None
Alcohol: None
Other: The patient currently at [**Hospital3 2558**] Nursing
Center, previously living in a home one floor above her
daughters
.
Family History:
Family History: Father had DM, CAD, HTN. No cancer or stroke in
family.
.
Physical Exam:
Physical Exam on ICU admission:
Vitals: T: 97.1 BP:152/58 P: 87-97 R:12 18 O2: 100% 1L
Gen: NAD, AAOx2-3
HEENT: moist mm, EOMI grossly, OP clear
Neck: Supple
CV: +s1+s2 RRR, II/VI SEM
Resp: Mild crackles at bases bilaterally, no rales/wheezes
Abd: +bs, well-healing midline incision, soft, NTND, no rebound
or guarding, no palpable masses.
Ext: 2+ pitting edema bilaterally to knees, chronic venous
statis
changes, LE warm and well perfused, faint DP pulses bilaterally.
GU: foley in place and urine with gross pus
Neuro: CN: II-XII, grossly intact. Moving all extremities.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
Labs from [**Hospital3 **]:
HCT 25.4
INR 4.4
BUN 59
creatinine 3.4
K 5.4 (? given kayexelate).
note that was holding lasix x 3 days and giving 500ml po fluid
per shift.
.
[**Hospital1 **] labs:
.
[**2130-3-31**] 10:02PM WBC-11.7* RBC-2.88*# HGB-8.7*# HCT-26.5*#
MCV-92 MCH-30.3 MCHC-32.9 RDW-15.6*
[**2130-3-31**] 10:02PM NEUTS-86.2* LYMPHS-9.0* MONOS-4.3 EOS-0.3
BASOS-0.3
[**2130-3-31**] 10:02PM PLT COUNT-189
[**2130-3-31**] 04:10PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2130-3-31**] 04:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2130-3-31**] 04:10PM URINE RBC-[**12-24**]* WBC->50 BACTERIA-MOD
YEAST-NONE EPI-0
[**2130-3-31**] 12:56PM PH-7.48* COMMENTS-GREEN TOP
[**2130-3-31**] 12:56PM GLUCOSE-92 LACTATE-1.2 NA+-137 K+-4.7
CL--113* TCO2-18*
[**2130-3-31**] 12:56PM HGB-5.3* calcHCT-16
[**2130-3-31**] 12:56PM freeCa-1.02*
[**2130-3-31**] 12:45PM GLUCOSE-94 UREA N-68* CREAT-3.6* SODIUM-139
POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-17* ANION GAP-15
[**2130-3-31**] 12:45PM ALT(SGPT)-19 AST(SGOT)-27 LD(LDH)-280*
CK(CPK)-100 ALK PHOS-397* TOT BILI-0.4
[**2130-3-31**] 12:45PM CK-MB-5
[**2130-3-31**] 12:45PM cTropnT-0.10*
[**2130-3-31**] 12:45PM ALBUMIN-1.8* CALCIUM-7.1* PHOSPHATE-6.0*
MAGNESIUM-1.8 IRON-30
[**2130-3-31**] 12:45PM calTIBC-108* VIT B12-1095* FOLATE-4.0
HAPTOGLOB-248* FERRITIN-645* TRF-83*
[**2130-3-31**] 12:45PM NEUTS-89.5* BANDS-0 LYMPHS-7.1* MONOS-3.0
EOS-0.2 BASOS-0.2
[**2130-3-31**] 12:45PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2130-3-31**] 12:45PM PLT COUNT-269
[**2130-3-31**] 12:45PM PT-48.6* PTT-46.2* INR(PT)-5.3*
[**2130-3-31**] 12:45PM RET AUT-3.3*
.
Micro:
Urine cx [**2130-3-29**]:
URINE CULTURE (Final [**2130-3-31**]):
YEAST. >100,000 ORGANISMS/ML.
urine culture [**4-1**]: 10,000-100,000 yeast
Images:
[**2130-3-31**] CXR Pa/lat:
UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: There are low
inspiratory lung volumes. Heart size remains enlarged but
unchanged. Pulmonary vascularity is not engorged. Bibasilar
opacities are noted, slightly worse on the right compared to the
prior study, which may reflect atelectasis. There are small
bilateral pleural effusions which are stable. Clips from prior
thyroidectomy are present. S-shaped scoliosis of the thoracic
spine is again noted.
IMPRESSION: Bibasilar airspace opacities, slightly worse on the
right, likely reflective of atelectasis. Infection is not fully
excluded. Small bilateral pleural effusions, unchanged.
.
CT abd/pelvis without contrast [**2130-3-31**]:
Evaluation of visceral organs is limited due to lack of
intravenous contrast.
Small bilateral pleural effusions with adjacent areas of
compressive
atelectasis are unchanged. Pleural based hyperdensity within the
right lung base is unchanged. Extensive coronary calcifications
are noted.
There is no evidence of retroperitoneal hematoma. Moderate
amount of ascitesis unchanged from [**2130-3-21**] exam. Focal
calcifications of the liver and spleen, likely represent prior
granulomatous disease. Tiny calcified gallstones are noted
within the gallbladder. The pancreas and adrenal glands appear
unremarkable. Bilateral renal hypodensities, most likely renal
cysts, unchanged. There is no evidence of mesenteric or
retroperitoneal lymphadenopathy. Intra-abdominal aorta is
notable for calcified atherosclerotic disease without aneurysmal
changes. There is no free air within the abdomen.
.
CT OF THE PELVIS [**2130-3-31**]:
Moderate amount of fluid within the pelvis is unchanged. The
rectum, bladder, and sigmoid colon appear unremarkable. Moderate
sized fat-containing right inguinal hernia appears unchanged.
There is no free air within the pelvis. Generalized anasarca is
noted.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
identified. Grade 1 anterolisthesis involving L4-L5 is
unchanged.
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. In comparison to [**2130-3-21**] exam, there are no significant
change in moderate amount of ascites within the abdomen and
pelvis.
3. Small bilateral pleural effusions with adjacent areas of
compressive atelectasis, unchanged.
4. Cholelithiasis.
.
Echo [**2130-2-14**]:
The left atrium is elongated. 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%). Doppler
parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a very small pericardial
effusion.
IMPRESSION: Moderate symmetric LVH with normal global and
regional biventricular systolic function. Calcific aortic valve
disease with mild stenosis/mild regurgitation. Mild mitral
regurgitation. Moderate pulmonary hypertension. Very small
pericardial effusion.
.
Lower extremity dopplers - negative DVT
.
Venous ultrasound [**2130-2-15**]:
FINDINGS: Waveforms of the subclavian veins are symmetric
bilaterally. On the left, the internal jugular vein is notable
for isoechoic endoluminal contents and that vessel is
incompletely compressible and shows only partial flow on color
Doppler analysis, consistent with non-occlusive thrombus. The
left axillary, basilic and one of the left brachial veins are
normal with appropriate compressibility and wall-to-wall flow on
color analysis. The
second left brachial vein shows absent compressibility and no
flow on color Doppler analysis. The cephalic vein is not
identified, though note is made of subcutaneous edema in the
expected region of the cephalic vein.
IMPRESSION: Left deep venous thrombosis involving the internal
jugular and brachial veins. Cephalic vein not identified.
.
.
EKG: Old t wave inversion in I and AVL
Brief Hospital Course:
77 year old woman who presented from [**Hospital3 **] for high INR
(5.3), HCT of 16.9, and no clear source of bleeding. The HCT
drop was from 25.7 to 16.9 in 2 days. She had no clear GI
bleeding. She had Guaiac negative stools in ED and in ICU. She
had recent laparotomy for perforation of duodenal ulcer at OSH
on [**2130-3-10**] so initially there was concern for possible
intraabdominal bleed. CT torso showed no evidence of internal
bleeding. Folate and B12 levels were normal. With normal
bilirubin, elevated hapto and only marginally elevated LDH
hemolysis seemed unlikely. Both ASA and coumadin were held. She
was admitted to the ICU for close observation, although her
hemodynamics were stable. She received 4 units of blood and 3
units of FFP. HCT increased appropriately and have remained
stable in the mid 30s. The exact cause of her presenting anemia
remained unclear. She did not undergo endoscopy. She received
one dose of coumadin 2.5 mg on [**4-2**] while in the ICU for history
of DVT. Subsequently her INR continued to rise significantly to
6.8. We sought the input of our hematology consult service. They
felt that the increase was due to coumadin, given recent
antibiotics use and poor nutritional status. In regards to her
upper extremity DVT, it was line-associated and has been
anticoagulated since then. Hematology advised that the
risk/benefit ratio favors discontinuing anticoagulation. She had
persistent pyuria in urine and several cultures showed yeast. Of
note, several days prior to admission she was initiated on cipro
for pyuria, although this proved not to be a bacterial
infection. This admission our ICU initiated fluconazole, but we
have since discontinued it due to above INR issues. She remained
asymptomatic. The patient had stage IV renal failure and
hyperkalemia from Losartan. Losartan was discontinued and
received several doses of kayexalate. Her discharge was delayed
because of hyperkalemia and her discharge potassium was 5.0. Her
home lasix was held at nursing facility but we increased the
dose as she had severe edema up to the chest wall and
hypoalbuminemia (anasarca; bilateral pleural efusions and
ascites). Because of her low GFR, lower doses of Lasix are
usually ineffective. We found no portal hypertesnion or
thrombosis on ultrasound and no liver cirrhosis. The patient has
a recent history of pancreatitis/pancreatic head enlargement on
ultrasound from prior admission 1/[**2130**]. Ultrasound mentions
multiple pancreatic cystic structures which may be related to
pseudocyst formation and/or previously characterized side branch
IPMN. Given these findings we have recommended GI follow-up in
clinic. Her PCP was also notified of these findings although she
has been unable to see him lately because of her stays in rehab.
We also diagnosed her with stage III decubitus ulcer upon
admission. She had no clinical wound infection. We stopped the
Losartan, Clonidine and Hydralazine and increased the Metoprolol
and she remained normotensive. Her avarage in hospital BP in
fact was low (124/76). If she becomes hypertensive hydralazine
50 mg Tablet every 8 hours can be restarted. She was DNR/DNI but
family needs to consider comfort measures only. She was
disharged back to [**Hospital3 **] but to a different floor per
family request. PCP can reconsider starting aspirin only.
Potassium should be monitored with her low potassium diet.
Medications on Admission:
-amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
-metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO q 8 hrs ??????? daily
-hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
-omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily
-acetaminophen 650mg q6hrs prn
- sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
-humalog sliding scale
-tylenol 650mg every q 6 hrs
-aspirin 81mg daily
-Wellbutrin 100mg daily
-clonidine 0.2 mg/24 hr 1 patch QFRI
-levothyroxine 50 mcg po daily
-hydralazine 50mg q 8hrs
-warfarin being held
-lasix 40mg daily (holding since [**3-29**])
-losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
-prednisone 5 mg daily
.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for GI
upset.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
13. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
coolige house
Discharge Diagnosis:
coagulopathy from coumadin
anemia, blood loss?
deep venous thrombosis of upper extremity
Type II DM without treatment
pancreatic lesion
stage III decubitus ulcer
hyperkalemia
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:
You were admitted with anemia (low red blood count) and abnormal
labs that showed your blood was too thin. The exact cause is not
clear, but we do believe that you are very sensitive to blood
thinning medicines. You received several transfusions in the
ICU, where you stayed for close monitoring. A CT scan showed no
sign of bleeding in your abdomen, and your stool was also
negative for blood.
The blood thinner (that you were previously taking for the clot
in your arm) has been stopped.
A review of your prior imaging studies from your [**2130-2-4**]
admission for pancreatitis also showed an ultrasound with some
cystic changes and enlargement in an area of your pancreas. You
should see a GI specialist to further evaluate and follow-up
these findings.
Your potassium was elevated and you were placed on a low
potassium diet. Some of your BP medications were stopped
including a medication that elevates the potassium level
(losartan). Please follow up with your PCP in regards to your
potassium, Losartan, need for Aspirin, and anemia
Followup Instructions:
The patient needs GI follow-up for pancreatic changes with
possible IPMN (tumor) mentioned on ultrasound [**2-/2130**] if family
and patient want to pursue it further.
Department: RHEUMATOLOGY
When: THURSDAY [**2130-5-11**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"585.4",
"286.9",
"244.9",
"250.00",
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"453.86",
"276.7",
"112.2",
"707.23",
"707.03",
"E934.2",
"263.0",
"280.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16735, 16775
|
11291, 14689
|
385, 452
|
16993, 16993
|
4962, 11268
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480, 2426
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17008, 17146
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2904, 3985
|
4019, 4189
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,128
| 108,958
|
16581
|
Discharge summary
|
report
|
Admission Date: [**2177-5-28**] Discharge Date: [**2177-6-25**]
Date of Birth: [**2121-2-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Plasmpheresis
Ultrafiltration
Intubation
Central Line placement
History of Present Illness:
This is a 56 year old male with a history of Osteomylitis of the
right foot (recent admit at [**Hospital1 **]), CAD (s/p MI and stend in [**2161**],
and [**2174**], ?sternotomy?), CHF (?diastolic v. right sided from
PAH/pulm stenosis), moderate pulm artery HTN based on echo,
pulmonic stenosis, A-fib who was recently diagnosed with CML,
not started on treatment yet, who was transferred to [**Hospital 18**]
medical floor on evening of [**5-28**] for further managment of
osteomylitis.
.
On the medical floor a history was moaning and a history and ROS
was unable to be attained. He was noted to be volume overloaded
and given his respiratory distress he was given lasix. His
respiratory status continued to decline. An ABG was 7.28/45/65.
He was transferred to the unit for respiratory distress.
.
Review of systems:
Unable to attain secondary to patient somnolence
Past Medical History:
CAD s/p MI with stent in [**2161**]
CHF
Atrial fibrillation on Coumadin
Diabetes Type 2 on Insulin
Hypertension
Hyperlipidemia
CML (new diagnosis)
Peripheral [**Year (4 digits) 1106**] disease s/p R SFA stent angioplasty and L
SFA stent placement
Lower extremity cellulitis with surgical debridement/VAC
Brain Tumor s/p craniectomy
Gastroporesis
Neuropathy
Congenital Pulmonic Stenosis
Chronic indwelling foley.
Depression diagnosed at [**Hospital3 **], refused SSRIs
Social History:
Nonsmoker, no alcohol consumption
Family History:
No history of renal failure or disease. Mother with ? [**Name2 (NI) **]
dyscrasia
Heart disease in unspecificed family members.
Physical Exam:
General: Oriented to self. In moderate respiratory distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, unable to assess JVP.
Lungs: Rhales b/l at bases.
CV: Tachy, S1+, S2+, +systplic murmur, III/VI.
Abdomen: Diffusely tender. +gaurding. No rebound. Non-distended.
GU: foley
Ext: Cold, right foot dressed.
Pertinent Results:
CYTOGENETICS:
FISH evaluation for a BCR-ABL rearrangement was performed
on nuclei with the Vysis LSI BCR/ABL Dual Color, Dual
Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for BCR at
22q11.2 and ABL at 9q34, and is interpreted as ABNORMAL.
Rearrangement was observed in 92/100 nuclei, which exceeds
the normal range (up to 1% dual rearrangement) for this
probe in our laboratory. A BCR-ABL rearrangement is found
in most cases of CML, and in a subset of cases of ALL and AML.
.
BONE MARROW BIOPSY:
FISH evaluation for a BCR-ABL rearrangement was performed
on nuclei with the Vysis LSI BCR/ABL Dual Color, Dual
Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for BCR at
22q11.2 and ABL at 9q34, and is interpreted as ABNORMAL.
Rearrangement was observed in 95/100 nuclei, which exceeds
the normal range (up to 1% dual rearrangement) for this
probe in our laboratory. A BCR-ABL rearrangement is found
in most cases of CML, and in a subset of cases of ALL and AML.
.
FOOT X-RAY:
1. Evidence of cortical destruction and loss at the fifth
metatarsal head and neck on the right, either due to
osteomyelitis or prior debridement.
2. Faint lucency through navicular on the right of uncertain
significance. Correlate with focal symptoms.
3. Some loss of morphology of the right calcaneus is seen, but
no frank
cortical destruction.
4. Probable left fifth metatarsal base fracture.
5. Area of relative lucency and cortical ill definition at the
medial aspect of the left fifth metatarsal head may represent an
area of cortical
destruction due to osteomyelitis, although the appearance is
nonspecific.
.
PATHOLOGY BONE BIOPSY 5th METATARSAL HEAD:
Bone, right fifth metatarsal head (A):Regenerative bone and
fibrous tissue with focal acute inflammation, consistent with
ulcer bed; no acute osteomyelitis seen. Small juxta-trabecular
lymphoid aggregate.
.
CT ABDOMEN/PELVIS/CHEST ([**2177-5-30**]):
1. Large left and small right pleural effusions with question of
loculation superiorly, as before, though this come be from
chronic pleural scar. Interstitial thickening consistent with
mild pulmonary edema.
2. Mild-to-moderate ascites around the liver and tracking into
the pelvis.
Diffuse anasarca, consistent with third spacing.
3. No evidence of acute bowel abnormality. No hemoperitoneum or
pneumoperitoneum to suggest splenic rupture or bowel
perforation.
4. Extensive coronary artery atherosclerotic calcification.
5. Enteric tube sideport situated above GE junction; advance for
standard
positioning.
.
ECHOCARDIOGRAM ([**6-17**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%). The anterior septum appears hypokinetic. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. The pulmonic valve leaflets are
thickened. There is moderate pulmonic valve stenosis.
Significant pulmonic regurgitation is seen. The main pulmonary
artery is dilated. The branch pulmonary arteries are dilated.
There is no pericardial effusion.
IMPRESSION: Compared with the findings of the prior study
(images reviewed) of [**2177-5-30**], no obvious change but the
technically suboptimal nature of both studies precludes
definitive comparison.
.
LABS AT THE TIME
[**2177-6-25**]:
WBC 5.5
HB 8.5
HCT 25.0
PLT 100
Na 138
K 4.0
Cl 99
CO2 30
BUN 35
Creat 2.4
Ca 9.6
Mg 1.6
Phos 2.1
HBsAg Negative
HBsAb Borderline
HBcAb Negative
PPD negative
MRSA swab positive
Brief Hospital Course:
MICU COURSE [**Date range (3) 47033**]
.
56 yo M with PMH of CHF, PVD, recent dx osteomyelitis on
linezolid and irtepenem, newly dx'ed CML, pulmonic stenosis, CAD
and DM was transferred from an OSH for further management of
CML. He was initially admitted to the floor and found to have a
white [**Date range (3) **] cell count of 280,000. He triggered for hypoxia and
delirium several hours after admission and was transfered to the
ICU. He was intubated for hypoxic respiratory failure and
delirium both thought to be [**12-31**] leukostasis.
.
.
# Hypoxic Respiratory Failure: Initially thought to be secondary
to pulmonary leukostasis. Also ulitmately from pulmonary edema
and ventilator associated pneumonia. Was plasmapheresed and
received chemotherapy as below. Also received significant
hydration in setting of uric acid of 14 and systemic
chemotherapy. Became massively fluid overloaded requiring
ultrafiltration intermittently. Spiked fevers and was bronched
which showed LLL PNA. Initially treated with linezolid,
cefepime and cipro which was narrowed to daptomycin and cefepime
to complete treatment for VAP. Stenotrophomonas grew from his
sputum but thought to be a colonizer as was clinially improving
not on bactrim. He had difficulty weaning from the ventilator
so tracheostomy was placed. With initiation of dialysis /
ultrafiltration and aggressive fluid removal he was able to be
weaned to trach mask. He was off the ventilator for > 24 hours
at the time of discharge.
.
# Leukemia: Had been newly diagnosed CML prior to admission.
WBC was 280K. Oncology was consulted on admission and the
patient was treated with Hydrea and Gleevec. He was started on
allopurinol. He underwent plasmapheresis once. Peripheral [**Month/Day (2) **]
was bcr-abl positive. Bone marrow biopsy was not adeuate for
further cytogenetics but was also bcr-abl positive, consistent
with accelerated CML, and he was continued on above treatment.
His white cell count decreased to normal range. In consultation
with the hematology oncology service, gleevac was stopped as
his WBC normalized and his hematocrit and platelet count were
low. Plan would be to restart if platelet counts become >150,000
or if white cell count increases. Gleevec dose would be 100mg
every other day. Allopurinol was stopped. He will follow up
with hematology-oncology.
.
# Acute Renal Failure: The acute on chronic renal insufficiency
was thought to be secondary to uric acid nephropathy. He
underwent ultrafiltration with volume removal. The renal failure
was initially non-oliguric and he was started on diuretics.
However, his urine output trailed off and his creatinine
worsened. He underwent placement of a tunneled line and was
started on alternating hemodialysis and ultrafiltration for
fluid removal. He was started on sevelemer but this was stopped
as his phosphate was low-normal. He should continue to have HD
on tuesday/thursday/saturday. Sevelamer should be restarted if
phosphate level rises. Epogen was started and should be given
with dialysis, 5500 units qHD.
.
# Ventilator acquired Pneumonia: Spiked fever and was bronched
showing LLL PNA. Treated with daptomycin (changed from
linezolid due to concern for marrow suppression), cefepime and
cipro for VAP.
.
# Hypotension: Was intermittently hypotensive requiring pressor
suppor which correlated to need for sedation and pain control as
had siginficant pain.
.
# Fever: Patient developed fever while intubated and was treated
with abx as above. Also treated with micafungin for several
days given he had significnat skin breakdown from anasarca and
concern for fungal infection. This was stopped once bronch
showed LLL PNA thought to be source of fever. HE defervesed
several days after bronchoscopy.
.
# Osteomyelitis: Diagnosed as OSH several days prior to
transfer with culture growing MRSA, VRE, and multiply resistant
Proteus. Initially treated with linezolid and irtepenem which
was changed to meropenem on admission. Podiatry was consulted
and took a bone swab which grew out nothing. Ultimately treated
with daptomycin (changed from linezolid due to concern for
marrow suppression) and cefepime (also covering for VAP in
presence of purulent sputum on bronch) for a total of 6 weeks,
last dose planned for [**2177-7-8**]. CBC, LFTs, CK, BUN/CREA should be
checked weekly and sent to infectious disease.
.
#Ventricular tachycardia: He developed asymptomatic
non-sustained ventricular tachycardia. He was evaluated by the
electrophysiology service. This was most likely due to ketamine,
which he was on for pain control. The ketamine was stopped and
the ectopy resolved. He was started on metoprolol for
suppression of ectopy.
.
# Thrombocytopenia: Developed in setting of chemotherapy and
systemic illness. Not thought to be HITT. Required
transfusions for <50 given GIB (see below) and procedures.
Linezolid changed to Daptomycin given concern for bone marrow
suppression.
.
# Anemia: Initially thought to be secondary to chronic illness,
chemotherapy. Developed acute [**Month/Day/Year **] loss anemia with melanotic
stool and hct drop to 19. GI scoped and saw esophagitis and
gastritis. Required transfusions on several occasions for
hct<21. He was continued on a PPI. HCT on discharge was 25.0.
.
# Acute Pain: Was in [**9-7**] pain on admission to ICU likely from
bony pain from his leukemia. Required significant amounts of
fenanyl while intubated to keep pain at [**2177-4-3**]. Used dilaudid
iv and ultimately a ketamine drip to control pain. He developed
ventricular tachycardia on ketamine so this was stopped. The
fentanyl was weaned down and he was transitioned to a fentanyl
patch with dilaudid PO PRN, which kept his pain at 5-7 which he
deamed tolerable.
.
#Atrial fibrillation: He has a history of atrial fibrillation on
coumadin. This was held in the setting of his hematocrit drop.
Coumadin was restarted at a dose of 5mg per day on [**2177-6-25**]. He
should have INR checked daily until therapeutic. HCT should be
monitored in the setting of anticoagulation given his GI Bleed.
Once INR is 2.0-3.0, please d/c the Heparin SC.
.
# Chronic Diastolic Heart Failure: Initial concern for
component of cardiogenic shock given hypotension and renal
failure. Echo showed normal EF though had poor windows.
Developed pulmonary edema in setting of massive fulid hydration
with chemo. Required lasix gtt, metolozone and ultimately
ultrafiltration.
.
# Rash: Pt with new erythematous, scaling rash on forehead. He
was started on a steroid cream with significant improvement.
.
# Ileus: Imaging showed no SBO. Treated with Reglan which was
then discontinued.
.
# Code: Full
.
FOLLOW-UP AT REHAB:
1. Hemodialysis on Tuesday/Thursday/Saturday, epo to be given
with HD
2. Start Sevelamer if Phosphate rises
3. When platelets > 150, or if WBC rise restart Gleevec at 100mg
every other day.
4. Check INR daily until range is 2.0-3.0, then drop dose to 4mg
daily.
5. Weekly labs to include CK, LFTs, Bun, creatinine and CBC. The
results of these labs should be faxed to the infectious disease
clinic at [**Telephone/Fax (1) 1419**] attention: Dr [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **].
Medications on Admission:
Home Medications:
Coumadin 4mg PO daily
Lantus 18 units SQ QHS
Novolog sliding scale
Methocarbamol 1g PO Q4hours
Dilaudid 4mg PO Q4h PRN Pain
Atarax 25mg PO Q6H prn Pain
Miralax 17g PO BID PRN Constipation
Albuterol PRN
Vitamin C 500mg PO Daily
MVI
Lasix 20mg PO BID
Metoprolol 25mg PO BID
Omeprazole 20mg PO BID
Simvastatin 20mg PO QHS
Lisinopril 5mg PO Daily
.
Transfer Medications from [**Hospital3 **]:
Linezolid 600mg PO Q12
Allopurinol 200mg PO BID
Miconazole topical [**Hospital1 **]
Robaxin 500mg PO Q6
Ertapenem 1g IV Daily
Dilaudid 0.5mg IV Q2hr PRN
Levemir 10 units SQ QHS
Colac 100mg PO BID
Ventolin 1 puff Q4
Novolog Sliding Scale
Ferrous Sulfate 325mg PO BID
Simvastatin 20mg PO Daily
Metoprolol 25mg PO BID
Omeprazole 40mg PO daily
Senna 2 Tabs PO BID
MVI 1 tab PO Daily
Ascorbic Acid 500mg PO BID
Mylanta 30mL Q4 PRN
Tylenol 650mg PO Q4H PRN pain
Zofran 4mg IV Q6 PRN
Discharge Medications:
1. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
2. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain, headache.
4. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
5. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: 2-8 units
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
6. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H (every
24 hours).
7. Fentanyl 100 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
9. Daptomycin 500 mg Recon Soln [**Hospital1 **]: Six Hundred (600) mg
Intravenous q48 hours for 13 days: LAST DOSE [**2177-7-8**].
10. Cefepime 1 gram Recon Soln [**Month/Day/Year **]: One (1) gm Injection once a
day for 13 days: ON HD DAYS, GIVE AFTER HD. LAST DAY = [**2177-7-8**].
11. Coumadin 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
12. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One Hundred (100) mg
PO BID (2 times a day).
13. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
injection Injection TID (3 times a day): please discontinue once
INR >2.
15. Lactulose 10 gram/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Hydromorphone 4 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
18. Epogen 10,000 unit/mL Solution [**Last Name (STitle) **]: 5500 (5500) units
Injection qHD.
19. Outpatient Lab Work
INR daily until therapaeutic ([**1-1**])
20. Outpatient Lab Work
CBC with differential, Chem-10, LFT, CK Qweek and fax results
to:
1. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (oncology) at ([**Telephone/Fax (1) 6023**].
2. Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1419**])
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Osteomyelitis
Hypoxic respiratory failure requiring intubation
Chronic respiratory failure requiring tracheostomy
Pneumonia
Chronic myelogenous leukemia
Renal failure requiring hemodialysis
Ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was our pleasure to participate in your care Mr. [**Known lastname 47031**]. You
were admitted to [**Hospital1 18**] for osteomyelitis. You were soon
transferred to the ICU for respiratory distress which was
likely due to fluid overload and pneumonia. You required
intubation with subsequent chronic respiratory failure requiring
tracheostomy. You were treated with broad spectrum antibiotics
for the osteomyelitis and pneumonia with a plan to continue a
course until [**2177-7-2**].
You developed acute renal failure and were evaluated by the
nephrology service. You required initiation of hemodialysis.
You developed a heart arrhythmia called ventricular tachycardia
and were evaluted by the electrophysiology service. This was
likely due to a medication you were on (ketamine), as it
resolved once the medication was stopped. You were started on
metoprolol to maintain the normal heart rhythm.
Your white [**Month/Day/Year **] cell count was found to be very high,
concerning for leukemia. YOu were evaluated by the
hematology-oncology team. Bone marrow biopsy was suggestive of
chronic myelogenous leukemia. You received plasmapharesis and
were started on a medication called gleevac. Your [**Month/Day/Year **] count
normalized and you will follow up with the hematology oncology
team for further management.
Followup Instructions:
1. You will follow up in the hematology oncology clinic with Dr.
[**Last Name (STitle) **] on [**7-8**] at 10:30AM. The phone number is
[**Telephone/Fax (1) **]. You should have your CBC, Chem-10 checked weekly
with the results faxed to attn: Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6023**].
2. You will follow up in the infectious disease clinic with Dr
[**Last Name (STitle) 12838**] on Tuesday, [**7-8**] at 3pm. You should remain on
daptomycin and cefepime until your appointment on [**7-8**].
While on Daptomycin and cefepime, you should have weekly labs to
include CK, LFTs, Chem-10, and CBC. The results of these labs
should be faxed to the infectious disease clinic at [**Telephone/Fax (1) 1419**]
attention: Dr [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **].
|
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|
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|
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9,798
| 157,196
|
30529
|
Discharge summary
|
report
|
Admission Date: [**2110-3-16**] Discharge Date: [**2110-3-25**]
Date of Birth: [**2038-4-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from OSH for acute MI.
Major Surgical or Invasive Procedure:
Cardiac catherization.
Bare metal stent placement.
History of Present Illness:
71 year-old Portuguese speaking man with history of HTN, DM who
noted indigestion/GI upset [**3-15**] with acute onset of dyspnea. EMS
as called and the patient was found to be saturating 70% on RA.
On arrival at [**Hospital3 **], VS BP 180/110, HR 92, sat to 89% on
6L then 97% on 100% NRB. Labs significant for CK 484, MB 31.9,
Index 6.6, trop 4.34, glucose 328, creatinine 2.1, WBC 22 (77%
PMN). He received lasix 40 mg IV x1 (700cc of urine in foley on
arrival) and combivent neb x1. He then received SLNGx1, aspirin,
plavix, heparin gtt, nitro gtt. ECG concerning for down-sloping
ST depressions (V4-V6); I and aVL; II, III, and aVF with ST
elevations in V1, V2, Q wave in III, TWI in V5, V6, II, III, aVF
(no old for comparison); axis and intervals WNL. He was
transferred to [**Hospital1 18**] for concern for STEMI.
.
On arrival he denied fevers, chills, cough, dyspnea, chest pain
or pressure, abdominal pain, nausea, vomiting. His family notes
that he complained of chills a few days prior, but otherwise has
been in his usual state of health. No known angina or dyspnea on
exertion.
Past Medical History:
1. Hypertension
2. Type II diabetes
3. Legally blind
4. History of burn requiring skin grafts
Social History:
Lives with wife at home. Ex smoker, quit 20 years ago, 1 PPD x
aprox 30 years, occ. etoh, denies illicit drug use.
Family History:
Unknown
Physical Exam:
VS: T 96.5 BP 153/102 HR 90 RR 27 SpO2 92% on 0.60% NRB
Gen: Pale, anxious appearing man breathing rapidly
HEENT: PERRLA, OP clear
Neck: No LAD, JVP to jaw
Resp: Diffusely rhonchorus with poor air movement and expiratory
wheezes, no distinct rales
CV: RRR, S1 S2 present but muffled, no distinct
murmurs/rubs/gallops
Abdomen: Obese, distended, NT, +BS, no masses
Extremities: No cyanosis, clubbing, edema, hyperpigmented skin
with decreased hair growth, 2+ DP/PT bilaterally, 2+ femoral
bilaterally, no femoral bruits
Skin: Scar tissue bilateral lower extremities
Pertinent Results:
[**2110-3-16**] 04:31AM PT-14.9* PTT-93.9* INR(PT)-1.3*
[**2110-3-16**] 04:31AM PLT SMR-NORMAL PLT COUNT-368
[**2110-3-16**] 04:31AM NEUTS-83.2* LYMPHS-9.3* MONOS-7.5 EOS-0
BASOS-0
[**2110-3-16**] 04:31AM WBC-23.3* RBC-4.34* HGB-12.6* HCT-37.8*
MCV-87 MCH-29.1 MCHC-33.3 RDW-13.4
[**2110-3-16**] 04:31AM CALCIUM-9.4 PHOSPHATE-4.5 MAGNESIUM-2.0
[**2110-3-16**] 04:31AM CK-MB-28* MB INDX-5.8
[**2110-3-16**] 04:31AM cTropnT-0.93*
[**2110-3-16**] 04:31AM ALT(SGPT)-47* AST(SGOT)-87* LD(LDH)-335*
CK(CPK)-485* ALK PHOS-74 TOT BILI-0.4
[**2110-3-16**] 04:31AM GLUCOSE-311* UREA N-46* CREAT-2.0*
SODIUM-129* POTASSIUM-4.0 CHLORIDE-90* TOTAL CO2-21* ANION
GAP-22*
[**2110-3-16**] 04:45AM LACTATE-5.2*
[**2110-3-16**] 04:53AM %HbA1c-7.6* [Hgb]-DONE [A1c]-DONE
[**2110-3-16**] 09:31AM LACTATE-3.0*
[**2110-3-16**] 09:31AM TYPE-ART PO2-79* PCO2-40 PH-7.43 TOTAL CO2-27
BASE XS-1
[**2110-3-16**] 11:14AM PLT COUNT-280
[**2110-3-16**] 01:00PM PLT COUNT-269
[**2110-3-16**] 01:00PM CK-MB-43* MB INDX-4.8 cTropnT-4.02*
[**2110-3-16**] 01:00PM CK(CPK)-900*
[**2110-3-16**] 01:00PM POTASSIUM-3.9
[**2110-3-16**] 05:55PM WBC-15.4* RBC-3.29* HGB-9.6* HCT-27.7*#
MCV-84 MCH-29.3 MCHC-34.7 RDW-13.1
[**2110-3-16**] 05:55PM PLT COUNT-255
[**2110-3-16**] 05:55PM CALCIUM-8.6 PHOSPHATE-4.3 MAGNESIUM-1.8
[**2110-3-16**] 05:55PM CK-MB-35* MB INDX-4.1 cTropnT-4.61*
[**2110-3-16**] 05:55PM CK(CPK)-854*
[**2110-3-16**] 06:47PM URINE RBC-6* WBC-4 BACTERIA-FEW YEAST-NONE
EPI-[**3-24**]
[**2110-3-16**] 06:47PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2110-3-16**] 06:47PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.022
[**2110-3-16**] 08:17PM CK-MB-24* MB INDX-3.5 cTropnT-4.56*
[**2110-3-16**] 08:17PM CK(CPK)-692*
.
ECG Study Date of [**2110-3-16**] 4:28:02 AM
Sinus rhythm. Left ventricular hypertrophy with repolarization
abnormality.
Probable left atrial abnormality. Extensive ST-T wave
abnormalities may be due
to left ventricular hypertrophy, but may also be due to
ischemia. Clinical
correlation is suggested. No previous tracing available for
comparison.
.
C.CATH Study Date of [**2110-3-16**]
1. Selective coronary angiography of this right dominant system
shows
severe 2 vessel coronary artery disease. The LMCA is without
angiographically apparent disease. The pLAD has a long 70%
stenosis.
The LCx system is without obstructive coronary artery disease.
The mRCA
has a discrete 95% stenosis.
2. Resting hemodynamic study shows severely elevated left sided
filling
pressure with a PCWP of 29mmHg and pulmonary arterial
hypertension with
PAP of 54/28mmHg. The cardiac output was maintianed on dopamine
drip
with a cardiac index of 2.5.
3. Left ventriculography was not obtained as the LV filling
pressure
was quite high and the patient has chronic renal insufficiency.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severely elevated left sided filling pressure
3. Severe pulmonary hypertension
.
CT ABDOMEN W/O CONTRAST [**2110-3-16**]:
1. No evidence of retroperitoneal hematoma.
2. Moderate bilateral pleural effusions with associated
atelectasis.
3. Coronary artery calcifications.
4. Bilateral renal cysts. 1.5-cm relatively hyperattenuating
rounded lesion in the mid pole of the left kidney likely
represents a hyperdense cyst; however, this could be confirmed
with ultrasound.
5. Small hypodensity seen at the liver dome, possibly
representing a cyst versus partial voluming artifact. This could
also be confirmed with ultrasound.
6. Coronary artery calcifications.
7. Vascular calcifications and calcification of the vas
deferens, suggesting a history of diabetes.
8. Enlargement of the prostate.
.
ECHO Study Date of [**2110-3-17**]
Left Ventricle - Ejection Fraction: 20% to 25% (nl >=55%)
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. A left ventricular mass/thrombus cannot
be excluded. Overall left ventricular systolic function is
severely depressed with global hypokinesis and near akinesis of
the distal LV and apex. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**1-21**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2110-3-24**] 07:35AM 13.4* 4.53* 12.9* 38.6* 85 28.5 33.5 13.0
420
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2110-3-25**] 11:28AM 25.5* 30.3 2.6*
Brief Hospital Course:
71 year old Portugese speaking man with hypertension, diabetes
mellitus admitted with STEMI. He was taken to cardiac cath
shortly after arrival and found to have diffuse LAD disease and
a tight right coronary lesion which was stented. He was very
clear that he did not want CABG. His hospital course was
complicated by acute pulmonary edema and respiratory distress.
.
1. Cardiac:
a. Coronary artery disease: Cardiac cath showed LAD 70%
long-diffuse stenosis and RCA 95% mid-distal. Patient status
post bare metal stent to RCA. The patient was started on
aspirin, plavix, and high-dose statin. Metoprolol and enalapril
were initially held for hypotension but restarted one week prior
to discharge. The patient was started on a long-acting nitrate
for prevention of angina. The patient should have a resting MIBI
study as an outpatient to assess for reversible ischemia in the
LAD territory which was not re-perfused. The patient and his
family are adamantly against CABG and revascularization would
only be performed if amenable to stenting. The patient will
follow-up with Dr. [**Last Name (STitle) **] from cardiology.
.
b. Pump: EF 20% to 25%. The patient was given lasix for fluid
overload with good diuresis. The patient was restarted on
metoprolol and enalapril when blood pressure resolved. The
patient was started on coumadin for wall akinesis. The patient
should have a repeat echocardiogram in three months to evaluate
for need for ICD placement. The patient will follow-up with his
primary care doctor regarding his INR and coumadin dosing.
.
c. Rhythm: The patient remained in normal sinus rhythm. The
patient was restarted on metoprolol as above.
.
2. Shortness of breath: Secondary to pulmonary edema and then
pneumonia. The patient was intubated initially but weaned off
the ventilator. He was extubated without difficulty. The
patient was given lasix with good diuresis. He completed a
7-day course of levofloxacin for pneumonia after he developed
low-grade fever and leukocytosis. The patient was given
supplemental oxygen as needed.
.
3. Diabetes mellitus: The patient's metformin and avandia were
initially held for renal failure and cardiac cath. The
patient's renal failure did not improve to a level that
metformin could be restarted. The patient's hemoglobin A1C < 8,
almost goal. The patient's enalapril was restarted prior to
discharge. The patient's avandia was restarted prior to
discharge. The patient will follow-up at [**Last Name (un) **] for further
diabetes care.
.
4. Renal failure: The patient's baseline creatinine was unknown;
no labs available from the patient's primary care physician.
[**Name10 (NameIs) **] patient's likely has underlying chronic kidney disease
secondary to hypertension and diabetes. During admission, the
patient had acute renal failure likely secondary to
contrast-induced nephropathy with FeUrea 240%. Creatinine
improved to 1.8 prior to discharge.
.
5. Hyperlipidemia: Lipid profile at goal with LDL < 100. The
patient was continued on atorvastatin 80 po QD.
.
6. Psychiatric: Patient has history of depression and anxiety.
The patient's fluoxetine and klonapin were initially held but
restarted prior to discharge.
.
7. Legally blind: The patient was continued on his outpatient
regimen of eye drops.
.
8. Code: Full, but family reports patient would not want to be
kept alive by artificial means if no hope for recovery.
.
9. Disposition: Home with PT
Medications on Admission:
Ratenolol/chlorthal 100/25 mg po qd
Fluoxetine 20 mg po qhs
Avandia 4 mg po qd
Clonazepam 1 mg po qam
Metformin 1000 mg po bid
Simvastatin 40 mg po qd
Enalapril 20 mg po qd
Prednisolone Acetate 1 % drops
Brimonidine 0.15 % drops
.
Medications on transfer:
heparin gtt
plavix 300mg
aspirin 162mg
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
8. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*2*
12. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Outpatient Lab Work
Basic metabolic panel, INR.
Thursday, [**3-27**].
14. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Primary:
1. STEMI s/p bare metal stent to RCA
2. Congestive heart failure
3. Pneumonia
.
Secondary:
1. Hypertension
2. Type II diabetes
3. Legally blind
4. History of burn requiring skin grafts
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were hospitalized with a heart attack and fluid in your
lungs from heart failure. You should take all your medications
as directed. You should restrict your salt intake to 2 grams per
day. You should restrict your fluid intake to 1 liter per day.
You should weigh yourself every day and call your doctor if your
weight is increased by more than two pounds. You should follow
the activity guidelines provided to you and work with physical
therapy.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, or any other concerning
symptoms.
.
Please take your medications as prescribed.
Your heart medications were changed as follows:
- Stop taking Tenoretic (atenolol/hydrochlorothiazide).
- Stop taking Simvastatin.
- Take Aspirin 325 mg once daily.
- Take Plavix 75 mg once daily.
- Take Metoprolol 125 mg twice daily.
- Continue Enalopril 20 mg once daily.
- Take Lipitor 80 mg once daily.
- Take Imdur 30 mg once daily.
- Take Lasix 40 mg twice daily. You will need blood levels of
electrolytes checked at your primary care appointment.
- Take Coumadin 5 mg once daily. You will need blood levels
checked in two days and usually once to twice a week per your
primary care doctor.
- You will follow-up with Dr. [**Last Name (STitle) **] regarding your heart care.
.
Your diabetes medications were changed as following:
- Stop taking Metformin.
- Continue taking Avandia 4 mg once daily.
- You will follow-up with Dr. [**First Name (STitle) 1557**] at the [**Last Name (un) **] Institute
regarding your diabetes care.
.
No change were made to your eye drops or psychiatric
medications.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Follow-up with in primary care doctor, Dr. [**Last Name (STitle) 11791**]: Thursday,
[**3-27**] at 1:30pm. Please call [**Telephone/Fax (1) 72506**] with any questions
or concerns. You will have blood work checked at this time for
levels of your blood thinner, coumadin.
.
Follow-up with your new diabetes doctor: [**4-1**] at 8:30am at
the [**Last Name (un) **] Institute with Dr. [**First Name (STitle) 1557**]. Please call [**Telephone/Fax (1) 2378**]
with any questions or concerns.
.
Follow-up with your new heart doctor: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2110-4-21**] 8:00. [**Hospital Ward Name 23**]
building, [**Location (un) 436**].
|
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icd9cm
|
[
[
[]
]
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[
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14545, 15260
|
1787, 1796
|
11141, 12475
|
12567, 12763
|
10821, 11052
|
5314, 7337
|
12840, 14522
|
1811, 2377
|
275, 308
|
427, 1522
|
11077, 11118
|
1544, 1639
|
1655, 1771
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,563
| 134,268
|
23136
|
Discharge summary
|
report
|
Admission Date: [**2105-2-9**] Discharge Date: [**2105-2-18**]
Date of Birth: [**2034-6-21**] Sex: F
Service: HEPATOBILIARY SURGERY
This is a 70-year-old female who underwent an exploratory
laparotomy and a true-cut biopsy of the liver three times, a
wedge biopsy of the liver on [**2105-2-9**]. Her preoperative
diagnosis was a liver mass, probable pre-cholangic carcinoma,
left lobe intraductal dilatation. Intraoperatively she was
found to have poorly differentiated carcinoma of the liver.
Please see the operative note by Dr. [**Last Name (STitle) **] for further
information on the intraoperative course and procedure
details.
Postoperatively the patient was admitted for routine postop
care to the Surgical intensive care unit due to some low
urine output and volume hemodynamic instability. Immediately
postop the patient had a PA catheter inserted and required
some Neo for blood pressure and hemodynamic control.
On postop day one the patient was continued on Neonephrine
and her fluid status was reassessed continually by being in
the Intensive care unit. Her hydrochlorothiazide was
restarted. Her crit remained stable and her blood pressure
continued to improve with a normal systolic in approximately
120. She was afebrile with stable vital signs. On postop
day two the patient was given chest PT and out of bed and
Neonephrine was started to be weaned to tolerate a systolic
blood pressure of 110. Urine output remained a little bit
less but it remained well in the sense of 75 cc's an hour.
On postop day three Neo was down to 1.0. The patient
remained afebrile but did intermittently have some low grade
temperature to 100.6. Blood pressure remained well.
Occasional blood pressures lower than a systolic of 100 but
usually in the low 100's. She remained stable. Positive
urinalysis and Levaquin was started. The patient remained on
the floor on [**2105-2-13**] due to bed status, was felt to be able
to be a good candidate to the floor. On [**2105-2-14**] she
continued to have some decreased urine output over the
evening of the 11th and 12th and received some boluses. Due
to the potential chance for increased fluid instability the
patient was kept in the Intensive care unit for further
management and hemodynamic monitoring. On [**2105-2-14**] the
patient complained of intermittent shortness of breath and
with poor p.o. intake. She remained afebrile with systolic
blood pressure in the 90 to 100's. She was started on TPN
and p.o. Lasix.
On [**2105-2-15**] the patient was transferred from Intensive care
unit to the floor. Was ideally negative two liters,
continued to have a pretty good stable blood pressure off any
pressors and did not require any. On [**2105-2-16**] the patient did
well and had no problems however, the patient continued
monitoring her TPN, slowly started to be weaned to 1 liter on
the evening of the 14th. It was discussed whether or not her
Foley should be discontinued but due to the fact that she was
not very mobile it was best to keep the Foley in place. In
addition a Social Work meeting and case management
involvement, discussion with the family as well as the doctor
indicated that they would like to admit patient to Skilled
Nursing Facility for comfort measures. She was in agreement
and an initial screen was placed on [**2105-2-16**]. On [**2105-2-16**] the
patient was made DNR/DNI. The patient was screened on
[**2105-2-17**] and monitored. As per the requested TPN was stopped.
Foley was kept and adjusted for comfort. She continued to
diurese and was receiving 80 mg of Lasix p.o. twice a day on
the 15th but will be discharged on the 16th with 40 mg p.o.
twice a day.
The patient was discharged to an Extended Care Facility for
comfort measures. She is to follow-up with Dr. [**Last Name (STitle) **] in
approximately one week to remove her staples.
FINAL DIAGNOSIS:
1. Status post exploratory laparotomy and biopsy on [**2105-2-9**].
2. Left hepatic duct stricture.
3. Hypertension.
4. Postoperative hypotension.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg p.o. once daily
2. Lenazapril 30 mg p.o. once daily
3. Dilaudid 2 mg p.o. q two hours p.r.n.
4. Colace 100 mg tablet p.o. twice a day.
5. Midodrine 2.5 mg p.o. three times a day.
6. Albuterol inhaler q six hours p.r.n.
7. Spironolactone 100 mg p.o. once daily.
8. Ipratropium bromide nebulizer q 6 hours p.r.n.
9. Ativan 0.5 mg p.o. three times a day p.r.n.
10. Lasix 40 mg p.o. twice a day.
11. Insulin as per sliding scale.
The patient will be discharged as indicated above to Extended
Care Facility. Her anticipated day of discharge is [**2105-2-18**]
pending approval from the patient's family for the care
center that had accepted the patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Doctor Last Name 22186**]
MEDQUIST36
D: [**2105-2-18**] 14:50:36
T: [**2105-2-18**] 16:06:21
Job#: [**Job Number 59539**]
|
[
"789.5",
"571.5",
"572.3",
"156.9",
"458.29",
"197.7",
"576.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"99.07",
"50.11",
"89.64",
"50.12",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4093, 5054
|
3889, 4038
|
4063, 4070
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,294
| 199,426
|
33944+57882
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-11-18**] Discharge Date: [**2179-11-29**]
Date of Birth: [**2123-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tylenol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion/Fatigue
Major Surgical or Invasive Procedure:
[**2179-11-18**]
1. Bentall procedure with a 29-mm [**Company 1543**] Freestyle valve
(serial number [**Serial Number 78413**]) with coronary button
reimplantation.
2. Ascending aortic replacement and hemiarch replacement
with a 28-mm Vascutek Dacron tube graft (catalog number
[**Numeric Identifier 31950**]; lot number [**Serial Number 78414**]; serial number [**Serial Number 78415**])
using deep hypothermic circulatory arrest.
History of Present Illness:
56 year old gentleman whos cardiac history began in [**2177**]
folowing
a crushing fracture of his left tibia and fibula. He underwent
repair of this however his postoperative course was complicated
by osteomyelitis. He was eventually admitted in [**2178-1-12**]
with fevers and was found to have thickening of his aorta
consistent with aortitis and aortic valve endocarditis. Cultures
were negative. Of note, a temporal artery biopsy was neagative.
An echo ultimately revealed aortic valve endocarditis and aortic
insufficiency with a bicuspid aortic valve. Since that time he
has been followed with serial echocardiograms. His most recent
shows a markedly dilated aortic root and ascending aorta with
mild aortic stenosis and moderate aortic insufficiency. He has
noted progressive dyspnea on exertion as well as fatigue over
the
past several months. Given the progression of his disease, he
has
been referred back for surgical evaluation.
Past Medical History:
AV endocarditis, aortic stenosis, aortic insufficiency, dilated
aortic root and ascending aorta
PMH:
-Moderate aortic stenosis and moderate-to-severe aortic
regurgitation
-Status post AV endocarditis [**2177**] - 9 weeks vancomycin/cipro
-Inflammatory aortitis
-Dilated ascending aorta
-Osteomyelitis - Medullary nail
-Hypertension
-Dyslipidemia
-Dyspnea
-Patellar bursitis
-Gout
-Left tibia and fibular fracture
-Lower extremity DVT in [**2177-12-13**] in the setting of
immobilization post-surgery
Social History:
Lives with: Son in [**Name2 (NI) **], MA
Occupation:Truck mechanic
Tobacco: Denies
ETOH: Denies
Family History:
Both parents with heart disease in their 50's
Physical Exam:
Pulse: 74 SR Resp: 22 O2 sat: 98% RA
B/P 108/68
Height: 68" Weight: 240
General: A&Ox3, NAD
Skin: Dry, warm and intact. +Rhinophyma. Well healed surgical
scars of LLE. Right temporal 7-8mm lesion/excoriation with
central ulcer and small papule. ?Basal cell.
HEENT: NCAT, PERRLA, EOMI,Teeth in very poor repair.
Neck: Supple [X] Full ROM [X] JVD[]
Chest: Lungs ess. clear, scattered exp.wheezing bilaterally
Heart: RRR, NlS1-S2, II/VI systolic murmur
with a I/VI diastolic murmur.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] Obese
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Varicosity noted below knee on left. Mild dilation
of GSV branches below knee of right.
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:1
PT [**Name (NI) 167**]:2 Left:1
Radial Right:2 Left:2
Carotid Bruit- Right: none appreciated Left: None appreciated
Pertinent Results:
[**2179-11-23**] 05:10AM BLOOD WBC-8.8 RBC-3.47* Hgb-11.1* Hct-32.0*
MCV-92 MCH-31.9 MCHC-34.6 RDW-15.3 Plt Ct-183
[**2179-11-23**] 05:10AM BLOOD Glucose-102* UreaN-15 Creat-0.8 Na-136
K-4.1 Cl-101 HCO3-27 AnGap-12
[**2179-11-24**] 04:50AM BLOOD WBC-10.5 RBC-3.60* Hgb-11.4* Hct-32.8*
MCV-91 MCH-31.7 MCHC-34.8 RDW-15.1 Plt Ct-224
[**2179-11-24**] 04:50AM BLOOD Glucose-119* UreaN-14 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-27 AnGap-12
[**2179-11-18**] Intra-op TEE
Pre CPB:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
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 markedly dilated at the sinus level. The
ascending aorta is markedly dilated The aortic arch is mildly
dilated. There are simple atheroma in the descending thoracic
aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. Significant aortic stenosis is
present (not quantified). Severe (4+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric, directed toward
the anterior mitral leaflet.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
The tricuspid valve was not seen well.
Post CPB:
There is a bioprosthetic valve in the aortic position with mild
aortic insufficiency.
There is trivial mitral regurgitation.
There is an ascending aorta graft, otherwise, the visible
contours of the thoracic aorta are intact.
The biventricular systolic function is preserved.
Brief Hospital Course:
The patient was brought to the operating room on [**2179-11-18**] where
the patient underwent Bentall with 29mm Freestyle Porcine Aortic
Valve as well as replacement of ascending aorta with 28mm graft.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU on neo, in stable
condition for recovery and invasive monitoring. Vancomycin was
used for surgical antibiotic prophylaxis due to penicillin
allergy. POD 1 found the patient extubated, alert and oriented
and breathing comfortably. The patient was neurologically
intact and hemodynamically stable, weaned from inotropic and
vasopressor support. He did have serosanguinous drainage from
his sternal incision and had repeated low grade temperatures and
was started on vancomycin and levofloxacin as well as betadine
paint to the incision. All cultures were negative. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility.
By the time of discharge on POD #9 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions.
Medications on Admission:
Diovan HCT 320/25 daily
carvedilol 25 mg twice daily
aspirin 81 mg daily
Zocor 40 mg daily
Niacin 500 mg SR once daily
meclizine 25(1)
calcium-tums
magnesium
tramadol
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
4. niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
[**Date Range **]:*14 Tablet(s)* Refills:*0*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Date Range **]:*60 Tablet(s)* Refills:*2*
7. meclizine 25 mg Tablet Sig: One (1) Tablet PO once a day.
[**Date Range **]:*30 Tablet(s)* Refills:*2*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
[**Date Range **]:*14 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
[**Date Range **]:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
[**Date Range **]:*65 Tablet(s)* Refills:*0*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1514**] Health Care Center - [**Location (un) 1514**]
Discharge Diagnosis:
AV endocarditis, aortic stenosis, aortic insufficiency, dilated
aortic root and ascending aorta
PMH:
-Moderate aortic stenosis and moderate-to-severe aortic
regurgitation
-Status post AV endocarditis [**2177**] - 9 weeks vancomycin/cipro
-Inflammatory aortitis
-Dilated ascending aorta
-Osteomyelitis - Medullary nail
-Hypertension
-Dyslipidemia
-Dyspnea
-Patellar bursitis
-Gout
-Left tibia and fibular fracture
-Lower extremity DVT in [**2177-12-13**] in the setting of
immobilization post-surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] on [**2179-12-14**] at 2:00 PM
Cardiologist: [**Name8 (MD) 78416**] NP [**2179-12-31**] at 9:30 AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 78417**] in [**5-17**] weeks [**Telephone/Fax (1) 78418**]
**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:[**2179-11-27**] Name: [**Known lastname 12629**],[**Known firstname **] Unit No: [**Numeric Identifier 12630**]
Admission Date: [**2179-11-18**] Discharge Date: [**2179-11-29**]
Date of Birth: [**2123-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tylenol
Attending:[**First Name3 (LF) 1543**]
Addendum:
The patient was initially scheduled to be discharged home. After
further investigation of social issues it was deemed advisable
for the patient to have a short rehabilitation stay. He was
therefore dischargered to rehabilitation at [**Hospital **] Health Care
Center.
His discharge medications are listed below.
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. meclizine 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 30* Refills:*0*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
11. potassium chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
Follow-up is as scheduled below:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**2179-12-14**] at 1:00 PM [**Telephone/Fax (1) 1477**]
Cardiologist: [**Name8 (MD) 12631**] NP [**2179-12-31**] at 9:30 AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 12632**] in [**5-17**] weeks [**Telephone/Fax (1) 12633**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care Center - [**Location (un) **]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2179-11-29**]
|
[
"285.9",
"401.9",
"272.4",
"441.01",
"785.0",
"V12.51",
"424.1",
"274.9",
"423.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.59",
"38.93",
"39.61",
"38.45",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
12582, 12826
|
5185, 6629
|
318, 772
|
8913, 9012
|
3427, 4874
|
9800, 12559
|
2398, 2446
|
6847, 8254
|
8390, 8892
|
6655, 6824
|
9036, 9777
|
2461, 3408
|
250, 280
|
800, 1744
|
1766, 2268
|
2284, 2382
|
4884, 5162
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,246
| 160,593
|
34859
|
Discharge summary
|
report
|
Admission Date: [**2199-10-30**] Discharge Date: [**2199-11-9**]
Date of Birth: [**2128-3-22**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Ampicillin / Trimethoprim / Ciprofloxacin
Attending:[**First Name3 (LF) 16613**]
Chief Complaint:
Ms. [**Known lastname 1557**] presents for definitive treatment of her left ankle.
Major Surgical or Invasive Procedure:
[**2199-10-30**] left ankle fusion and [**Last Name (un) **]
History of Present Illness:
[**First Name8 (NamePattern2) **] [**Known lastname 1557**] was admitted for definitive treatment of left ankle
s/p left ankle fusion and open reduction of left ankle
dislocation, achilles lengthening and removal of external
fixator.
Past Medical History:
DMII- complicated by severe peripheral neuropathy (no sensation
from knees down), retinopathy s/p laser
Glaucoma
HTN
Legally blind
OCD
s/p amputations of 1st and 2nd toe of L foot
s/p pacemaker
Social History:
Lives alone, uses walker. Has VNA daily. Smoked 1-1.5 ppd x 40
years, quit in [**2190**]. No EtOH, or drugs.
Family History:
Non-contributory.
Physical Exam:
On discharge:
Afebrile, All vital signs stable
General: Alert and oriented, No acute distress
Resp: Reg even rate no audible wheeze
Cardiac: rrr, no rubs, murmurs, gallops
Extremities: left lower Incision: multiple suture areas
intact, medial malleoulus small 0.5 by 0.5 area open 0.5 deep
with betadine packing
[**Hospital1 **]-valveCast: clean/dry/intact Sensation intact to light
touch, Neurovascular intact distally, Capillary refill brisk,
2+ pulses,
Weight bearing: non weight bearing left lower extremity
Pertinent Results:
[**2199-10-31**] 06:35AM BLOOD WBC-9.8 RBC-2.64* Hgb-7.9* Hct-24.9*
MCV-94 MCH-30.1 MCHC-31.9 RDW-14.5 Plt Ct-251#
[**2199-10-31**] 06:35AM BLOOD Glucose-181* UreaN-15 Creat-0.9 Na-134
K-4.8 Cl-99 HCO3-31 AnGap-9
.
After Patient seized:
[**2199-11-3**] 04:53PM BLOOD WBC-13.7* RBC-2.68* Hgb-8.1* Hct-24.2*
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.9 Plt Ct-475*
.
[**2199-11-5**] 05:19AM BLOOD PT-13.3 PTT-32.6 INR(PT)-1.1
.
[**2199-11-3**] 04:53PM BLOOD Glucose-159* UreaN-13 Creat-0.9 Na-130*
K-3.3 Cl-84* HCO3-26 AnGap-23*
.
[**2199-11-4**] 04:54AM BLOOD LD(LDH)-194 CK(CPK)-257*
.
[**2199-11-3**] 04:53PM BLOOD CK-MB-3 cTropnT-0.04*
[**2199-11-4**] 04:54AM BLOOD CK-MB-5 cTropnT-0.05*
[**2199-11-4**] 02:51PM BLOOD CK-MB-5 cTropnT-0.06*
[**2199-11-4**] 10:42AM BLOOD %HbA1c-6.6*
[**2199-11-6**] 06:25AM BLOOD WBC-11.8* RBC-2.87* Hgb-8.6* Hct-26.5*
MCV-92 MCH-30.0 MCHC-32.5 RDW-15.9* Plt Ct-496*
[**2199-11-7**] 06:15AM BLOOD WBC-8.9 RBC-2.77* Hgb-8.5* Hct-25.2*
MCV-91 MCH-30.8 MCHC-33.7 RDW-16.4* Plt Ct-479*
[**2199-11-7**] 04:20PM BLOOD WBC-8.2 RBC-2.81* Hgb-8.7* Hct-25.7*
MCV-92 MCH-30.8 MCHC-33.7 RDW-16.3* Plt Ct-466*
[**2199-11-6**] 06:25AM BLOOD Neuts-72.5* Lymphs-16.7* Monos-9.4
Eos-0.8 Baso-0.6
[**2199-11-6**] 06:25AM BLOOD Glucose-157* UreaN-10 Creat-0.8 Na-140
K-4.3 Cl-104 HCO3-21* AnGap-19
[**2199-11-7**] 06:15AM BLOOD Glucose-101 UreaN-7 Creat-0.7 Na-141
K-3.7 Cl-105 HCO3-27 AnGap-13
[**2199-11-7**] 06:15AM BLOOD Calcium-7.9* Phos-1.6*# Mg-1.5*
.
CT HEAD: IMPRESSIONS: No evidence of hemorrhage. There is
evidence of chronic small- vessel ischemic disease. If acute
infarction remains a concern, MRI would be recommended for more
sensitive evaluation.
.
CT CHEST/Abd/Pelv: IMPRESSION:
1. Evaluation for pulmonary embolism somewhat limited due to
timing of
contrast bolus, respiratory motion, and CT artifact. While no
large or
central pulmonary embolism is seen, linear filling defects in a
subsegmental branch in the left upper lobe, also involving
segmental branch in the right upper lobe, could represent small
pulmonary emboli or could be artifactual.
2. Small right and trace left pleural effusion with dependent
atelectasis
bilaterally. Small amount of fluid tracks along the inferior tip
of the liver and along the right paracolic gutter. Trace fluid
in left paracolic gutter. Small free pelvic fluid. Anasarca.
3. Cardiomegaly. Atherosclerotic disease.
4. Intra- and extra-hepatic biliary ductal dilatation.
Gallbladder is not
seen.
5. Atrophic pancreas with dilatation of the pancreatic duct
along the
pancreatic head, also with calcifications surrounding and within
this
pancreatic duct.
6. No definite bowel abnormality is seen despite lack of oral
contrast
administration.
7. Multiple lymph nodes in the mediastinum, hila,
retroperitoneum, measuring up to 11 mm in short axis. In
addition, soft tissue measuring 2.2 x 1.7 cm surrounding the
right external iliac artery, which likely represents a lymph
node or lymph node conglomerate.
8. 4-mm hypoattenuating endometrial stripe; correlation with the
patient's
hormonal status is recommended.
Brief Hospital Course:
Mrs. [**Known lastname 1557**] was admitted to [**Hospital1 18**] on [**2199-10-30**] for an elective
left ankle arthordesis. Pre-operatively, she was consented,
prepped, and brought to the operating room. Intra-operatively,
she was closely monitored and remained hemodynamically stable.
She tolerated the procedure well without any complication.
Post-operatively, she was transferred to the PACU and floor for
further recovery. On the floor, post operative day one hct 24.9,
post operative day 2 continued to be evaluated by physical
therapy whom recommended rehab placement. She remained
hemodynamically stable. Her pain was controlled. She progressed
with physical therapy to improve her strength and mobility. She
developed diarrhea. C-Diff culture was negative.
.
[**Hospital Unit Name 13533**]: Patient was coded on the floor for
unresponsiveness. She had decorticate positioning with oral
tremors concerning for seizure. Ativan did not break the
seizure and the patient was intubated, but otherwise
hemodynamically stable. She was loaded with 1000mg IV phenytoin
which broke her seizure and Neurology was consulted. She was
extubaed on the following morning, remained stable >24hrs after
extubation and was transfered to the floor. CXR was concerning
for aspiration and patient complained of bladder spasms.
.
[**Hospital Unit Name 153**] Issues:
#. MS change/Seizures: Possible post-ictal. Patient's
electrolytes were corrected and Neurology was called for
possible etiologies of seizure. Explained it was most likely
toxic metabolic, involving either electrolyte abnormalities or
medication changes, but cannot rule out watershed infarcts or
new stroke.
- Extubated >24hrs, doing well
- 100 mg phenytoin per day - redose based on level
.
# Likely UTI: patient with lots of bladder pain overnight.
Afebrile overnight but WBC slight increase and with symptoms,
would emperically treat.
- UA and Culture sent
- started oxybutinin for symptomatic bladder spasms
- Started Cefipime based on antibiotic resistances.
.
# Pulmonary edema: Crackles throughout after large volume
resuscitation, only requireing 2L NC
- Lasix diuresis
.
#. Hyponatremia: resolved with fluid resuscitation
- NS bolus PRN
.
#. tachycardia, PVC: Corrected last PM
- electrolyte replacement PRN
.
#. Ankle fx: cont lovenox, ortho recs
.
#. anxiety: per family member pt with significant past panic and
anxiety attacs. perhaps contributed to patients situation
however doubt that this was a simple panic attact.
- sedation and proper treatment with haldol/ativan prn upon
extubation
.
On postop day #6, she was transferred back to the step-down
floor and remained stable. She got a Bivalve short leg cast.
She completed a 3 day course of IV antibiotics for presumed UTI.
She was discharged to a rehabilitation facility on [**2199-11-9**] in
stable condition.
Medications on Admission:
cyclogyl 1% eye drop, alphagen 15% eye drop, FeSo4 325,
Gabapentin 600 [**Hospital1 **], metoprolol 12.5 [**Hospital1 **], omeprazole 40 [**Hospital1 **],
sennakot 1 [**Hospital1 **], metocloperamide 5 qhs, remeron 15 qhs, ambiem
5qhs, ativan 0.5 [**Hospital1 **], celexa 40 qd, novolin 70/30 16u q5pm & 20u
q8am, sliding scale w/regular, oxycodone 5mg q4 prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg/0.4ml
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*qs 40mg/0.4ml* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 2-10 mg Tablets PO Q4-6H () as
needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection four times a day.
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: 2-4mg tablet
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
12. Zolpidem 5 mg Tablet Sig: 5 mg Tablets PO HS (at bedtime) as
needed for insomnia.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
14. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
16. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q6H (every 6 hours) as needed.
17. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
18. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
19. Phenytoin 100 mg IV Q8H
20. CefePIME 2 g IV Q12H
21. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection ASDIR (AS DIRECTED).
22. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
23. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 40149**] Nursing Home
Discharge Diagnosis:
left ankle fracture
Discharge Condition:
stable
Discharge Instructions:
If you experience any shortness of breath, new redness,
increased swelling, pain, or drainage, or have a temperature
>101, please call your doctor or go to the emergency room for
evaluation.
You may not bear weight on your left leg. Please use your
crutches for ambulation.
You may resume all of the medications you took prior to your
hospital admission. Take all medication as prescribed by your
doctor. You have been prescribed a narcotic pain medication.
Please do not drive or operate any machinery while taking this
medication. Feel free to call our office with any questions or
concerns.
Continue your Lovenox injections as prescribed to help prevent
blood clots. Please finish all of this medication.
Physical Therapy:
Activity: Activity as tolerated
Left lower extremity: Non weight bearing
Treatments Frequency:
Keep your cast clean and dry. Apply a dry sterile dressing daily
as needed for drainage or comfort. Keep your ankle dry for 5
days after your surgery. After 5 days you may shower, but make
sure that you keep your incision dry. Your skin staples may be
removed 2 weeks after your surgery or at the time of your follow
up visit.
Followup Instructions:
Provider: [**Name10 (NameIs) 13978**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2199-11-14**]
11:00
[**Name6 (MD) 13978**] [**Name8 (MD) **] MD [**MD Number(2) 16614**]
Completed by:[**2199-11-9**]
|
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"276.8",
"276.1",
"276.2",
"E888.9",
"357.2"
] |
icd9cm
|
[
[
[]
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] |
[
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,762
| 100,187
|
12660
|
Discharge summary
|
report
|
Admission Date: [**2107-1-17**] Discharge Date: [**2107-2-12**]
Date of Birth: [**2042-4-4**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Penicillins / Erythromycin Base / Demerol / Ceclor
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
64 yo woman w/ h/o recurrent PEs s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, GIB
while anticoagulated, COPD, who was discharged [**2107-1-12**] after
being treated for new PE presented to the ED with SOB and
productive cough. She was readmitted [**2107-1-17**] after she was
found to have a multifocal pneumonia and was treated with
Levo/Flagyl and Vanco. Cultures were positive for MRSA. Levo and
Flagyl were continued for suspected aspiration PNA. The pt
recovered quickly over since admission and she is now back on
her home O2 requirement. She was getting bridged for her
anticoagulation with Lovenox starting [**1-18**] in preparation for
discharge. However, she developed severe abdominal pain and a
palpable mass in her L abdomen. A CT was showed a new large
hematoma in the muscles of the left anterior and lateral lower
abdominal and pelvic wall, without any intraperitoneal or
retroperitoneal extent, but with associated mass effect on the
lower abdominal and pelvic bowel loops. Surgery was [**Month/Year (2) 4221**]
and suggested no intervention, but monitoring for now. HCT
dropped 6 points in this setting, but she remained
hemodynamically stable with tachycardia which has been present
throughout her hospital stay (95-115).
She required a total of 5 units PRBC and 4 units FFP
transfusions and was transferred to the MICU for further
monitoring. Her hematocrit has since been stable with serial
checks.
.
ROS: She has baseline left to mid chest pain with exertion that
is not currently bothering her. She denies current chest pain,
SOB, dysuria, increased urinary frequency. She has stable R knee
pain.
Past Medical History:
1. H/O Rheumatic Fever - age 8 -dx'ed last year with rheumatic
heart disease per pt (states ED diagnosed this) and has had
syndenham chorea
2. ?CHF per pt. although [**12-13**] Echo revealed low normal LVEF,
mildly thickened aortic and mitral valves with mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
3. Orthostatic hypotension
4. Chest pain - nearly monthly visits to ED with negative
ischemic w/u in the past
5. Duodenal/gastric ulcer
6. Seven miscarriages
7. Ulcerative colitis
8. Diverticulosis-s/p colostomy and reversal colostomy-had
Colonoscopy [**1-12**] showed only diverticuli without e/o active
bleed
8. Panic attacks x 15 yrs
9. Depression - several SA in past
10. Schizoaffective disorder
11. h/o polysubstance abuse
12. Iron deficiency anemia (baseline unclear-high 20's to 30's)
13. COPD
14. PE [**7-13**], c/b GIB while on anticoagulation, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter. New PE on [**2107-1-2**], again on anticoagulation
Social History:
Lives in lodge house. She has a homemaker help with her
cleaning. She gets meals on wheels. She has very limited funds.
Smoked 2 PPD X 40 yrs, quit smoking 4 months ago. Former
drinker, reports drinking two 6 packs per day for 2 yrs; quit 27
yrs ago. Denies h/o illicits and IVDA. H/O domestic violence.
Family History:
Daughter -40 - colitis. Had 6 siblings. One sister died, 35,
ovarian CA. Brother, died at 48, stroke. Sister, died at 64 from
infection. Father died at 65 of MI. Mom was "psychotic", died of
stroke at 93
Physical Exam:
VS: 97.6 HR 114, Bp 118/74 RR 20-30 Sats 98% 2L.
Gen: NAD, pleasant
HEENT: PEERLA, MMM.
Neck: supple, no LAD
Lungs: moderate air movement, decreased breath sounds at bases
CV: RRR, S1S2 present, distant heart sounds, no murmurs
Abd: +BS, S/ND, + umbilical hernia, ulcer mid abdomen-reportedly
chronic, unchanged, mildy errythematous base. no secretions.
Tenderness in L abdomen, palpable mass over unclear extension,
no guarding, no rebound
Back: no CVA tenderness.
Ext: 2+ on RLE, 1+ edema LLE/ no c/c/ 1+ DP
Neuro: A&Ox3, CN II-XII intact. moving all extremities.
Pertinent Results:
ADMISSION LABS:
[**2107-1-16**] 08:40PM PT-87.9* PTT-41.3* INR(PT)-11.8*
[**2107-1-16**] 08:40PM WBC-16.2*# RBC-3.63* HGB-11.6* HCT-33.5*
MCV-93 MCH-32.1* MCHC-34.7 RDW-14.0
[**2107-1-16**] 08:40PM NEUTS-90.5* BANDS-0 LYMPHS-4.7* MONOS-2.4
EOS-2.0 BASOS-0.5
[**2107-1-16**] 08:40PM GLUCOSE-127* UREA N-16 CREAT-1.0 SODIUM-136
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
[**2107-1-16**] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2107-1-17**] 12:47AM LACTATE-1.3
[**2107-1-22**] 03:07AM BLOOD WBC-7.5 RBC-2.85*# Hgb-8.6*# Hct-25.6*
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.4 Plt Ct-243
[**2107-1-22**] 03:07AM BLOOD PT-22.4* PTT-31.1 INR(PT)-2.2*
[**2107-1-22**] 03:07AM BLOOD Glucose-105 UreaN-11 Creat-0.6 Na-141
K-4.0 Cl-102 HCO3-35* AnGap-8
[**2107-1-22**] 03:07AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1
[**2107-1-23**] 04:34PM BLOOD PEP-HYPOGAMMAG IgG-535* IgA-254 IgM-109
.
CTA chest:
1. Interval development of patchy areas of consolidation with
mucous plugging, particularly in the right lower lobe, right
upper and mid lobes suggest a new infectious process or
aspiration.
2. Resolution of the previously identified pulmonary embolism.
3. Extensive centrilobular and paraseptal emphysematous change.
4. Fluid-attenuating structure adjacent to the right T11-12
neural foramen is also unchanged and could be a perineural cyst.
.
CT abdomen/pelvis:
1. New large hematoma in the muscles of the left anterior and
lateral lower abdominal and pelvic wall, without any
intraperitoneal or retroperitoneal extent, but with associated
mass effect on the lower abdominal and pelvic bowel loops.
2. Unchanged infectious or inflammatory opacities in the right
middle and lower lobes.
.
[**2107-2-1**] IR Embolization: 1. Right inferior epigastric
arteriogram demonstrates no extravasation of contrast and
successful embolization with Gelfoam until stagnation of flow.
2. The right internal mammary artery demonstrated no areas of
active extravasation of contrast.
.
[**2107-2-3**] CXR: There is an irregular opacity in the right lower
lobe
concerning for pneumonia. There are no pleural effusions.
There is no
pneumothorax. The left subclavian catheter tip overlies the mid
SVC. Heart size normal. Mediastinal and hilar contours are
normal. IMPRESSION: Opacity in the right lower lobe concerning
for pneumonia.
.
[**2107-2-8**] LENIS: Extensive occlusive thrombus is demonstrated from
the common femoral vein at the takeoff of the greater saphenous
vein extending distally to the popliteal veins bilaterally. No
color flow, compressibility, or waveforms are demonstrated
within these areas of thrombus. IMPRESSION: Extensive,
completely occlusive, bilateral deep venous thrombi extending
from the common femoral veins to the popliteal veins.
.
[**2107-2-9**] ECG: Sinus tachycardia, Normal ECG except for rate
Brief Hospital Course:
64F w/ h/o recurrent PE s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, GIB on
anticoagulation, COPD, recently admitted for new PE, readmitted
for multifocal PNA, who developed a large abdominal wall
hematoma in the context of enoxaparin injections.
# Multifocal Pneumonia: She was admitted with multifocal
pneumonia. She was started on levofloxacin and vancomycin. She
completed a 7 day course of levofloxacin. MRSA was found to
grow in her sputum so she was continued on a 14 day course of
vancomycin. She originally presented with elevated WBC count and
left shift which quickly resolved with the initiation of
antibiotics. Her productive cough improved as well and she
remained on her baseline home O2 of 2L. Approximately 4 days
after completion of her 14 day course of Vancomycin, the patient
developed worsening cough, SOB, and upper respiratory symptoms.
A repeat CXR showed evidence of a new consolidation in the RLL.
The patient was started back on Levofloxacin/Flagyl. Vancomycin
was added to her regimen when blood cultures showed 2/4 bottles
with GPC in clusters and chains. Additionally, her sputum
culture grew out GNRs. Levofloxacin was discontinued and
Meropenem was started for concern for Pseudomonas given the
patient's long hospital course. Her O2 sat remained stable
93-100% on 2L nasal cannula (which is her baseline). She was
given mucomyst inhaled nebulizers to assist in breaking up thick
sputum. Her GNRs in the sputum grew out E. coli. Because of
the sensitivity profile of the E. coli and the patient's allergy
to penicillin and cephalosporins, the patient was continued on
Meropenem. Her GPCs were found to grow out Coag negative Staph.
Surveillance cultures had no further growth and the coag
negative staph was thought to likely be a contaminant. Her
Vancomycin was discontinued. She will continue a 14 day course
of Meropenem and she was discharged with a PICC to complete this
course.
.
# Pulmonary embolism/DVTs: She has had multiple PEs and has had
one even since the placement of a TrapEase IVC filter. CT during
recent previous hospitalization revealed appropriate location of
filter and CTA on this admission showed improvement of clot.
Admission labwork revealed an INR of 7.9. Coumadin was thus
held and reversed with FFP and vitamin K given her history of
GIB on anticoagulation. In the interim, therapeutic lovenox
injections were initiated, but within days of starting, she
developed a large abdominal wall hematoma near to lovenox
injection site. Once her hematocrit stabilized, she was started
on a heparin gtt with coumadin overlap. While [**Last Name (NamePattern4) 9533**] her
Coumadin with an INR 1.2, she was found to have a large Hct drop
and a CT scan of the abdomen showed a new rectus hematoma. She
was subsequently transferred to the MICU for closer monitoring.
It was decided after her second hematoma while on
anticoagulation, the risks of anticoagulation outweigh the
benefits at this time and she was not anticoagulated. In terms
of her hypercoagulable workup, it has been negative thus far for
hyperhomocysteinemia, Factor V Leiden and antiphospholipid
antibody. Malignancy workup included a colonoscopy and EGD as
well as CEA, all of which were within normal limits. SPEP
revealed hypogammaglobulinemia, but was otherwise unremarkable.
During her hospital course, she also began to complain of
worsening lower extremity pain. LENIs were obtained which
showed evidence of extensive, completely occlusive, bilateral
deep venous thrombi extending from the common femoral veins to
the popliteal veins. Radiology felt that these clots were most
likely acute to subacute in nature. In this setting,
hematology/oncology saw the patient again to consider the risks
vs benefits of anticoagulation. Antithrombin III, prothrombin
mutation, Lupus anticoagulation and [**Location (un) 1169**] Venom Viper were
sent to reevaluate the reason for her hypercoagulability. The
hematology/oncology team still felt that the risks of
coagulation outweigh the potential benefits given that the
patient has had multiple bleeding episodes in the setting of
anticoagulation.
# Abdominal wall hematoma: As mentioned above, she developed a
large left-sided abdominal wall hematoma from a Lovenox
injection site that caused a significant hct drop (originally
28.1-->19.4). Despite the drop, she remained hemodynamically
stable (has sinus tachycardia at baseline prior to bleed). She
received 3 units prbcs, 4 units FFP. Her hematocrit then
stabilized and once stable, she was restarted on heparin gtt.
Coumadin was re-initiated and heparin gtt was continued while
awaiting her INR to become therapeutic. While [**Location (un) 9533**] her
Coumadin with an INR 1.2, she was found to have another Hct drop
(25.9-> 22.2) and a CT scan of the abdomen showed a new
right-sided rectus hematoma. She was subsequently transferred
to the MICU for closer monitoring. She was given 1 unit FFP and
9 units PRBCs between [**Date range (1) 39125**] until her hematocrit became
stable and she bumped appropriately to transfusion. It was
decided after her second hematoma while on anticoagulation, the
risks of anticoagulation outweigh the benefits at this time and
she was not anticoagulated. She has complained of [**6-16**]
abdominal pain with movement and has maintained stable
hematocrits. Her pain is most likely [**3-11**] to the large rectus
hematoma that will resolve over time. Her Hct remained stable
after her anticoagulation was discontinued.
# Thoracic mass: CT chest and abdomen revealed a stable
thoracic mass (stable x 3years) and thought potentially
consistent with neural cyst. It was not further evaluated by
MRI given its long term stability and also she has metal
hardware in place s/p elbow surgery and facial plates. It
should be followed up with imaging to ensure it remains
unchanged in the future.
# ? Zoster: Patient reports having a history of "herpes" on her
right buttock. During her stay, she developed a tingling,
itchiness and multiple small erythematous skin lesions on her
right buttock over the S2, S3 dermatomal distribution. There
were no vesicles appreciated. She was treated with acyclovir.
# Candidal vaginitis: Treated with fluconazole x 2 with
resolution of symptoms.
# H/o GI bleeding during recent admission: Recent colonoscopy
showed diverticulosis with no active signs of bleeding. She had
no blood in her stools during this admission even while
anticoagulated. Her stools were guiac-ed multiple times and
were found to be guiac negative.
# Constipation: She is constipated at baseline and requires
daily scheduled bowel regimen to maintian regularity.
# Hyperlipidemia: Continued on lipitor.
# Depression/SAD: Continued on Prozac, risperdone, wellbutrin,
and klonopin.
# Ulcerative Colitis: Remains in remission. She was continued
on mesalamine.
# Orthostatic hypotension: She remained asymptomatic even while
ambulating with physical therapy. She was continued on
midodrine.
Medications on Admission:
1. Fluoxetine 30 mg daily
2. Risperidone 3 mg PO HS
3. Bupropion SR 150 mg [**Hospital1 **]
5. Nicotine 7 mg/24 hr Patch
6. Hexavitamin daily
7. ascorbic acid 500 tab 1 [**Hospital1 **]
8. Calcium Carbonate 500 tab [**Hospital1 **]
9. Ferrous gluconate 325 PO daily
10. Atorvastatin 20 mg daily
11. Fluticasone Salmeterol 250/50 [**Hospital1 **]
12. Midodrine 5 mg tab 1 TID
13. Tiotropium bromide capsule one cap /day
14. Mesalamine 1200 TID
15. Pantoprazole 40/ day
16. Albuterol nebs prn (tid generally)
17. docusate sodium
18. Warfarin 5 mg/day
19. Ipratropium nebs prn (tid generally)
20. clonazepam 1mg po tid
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please do not take this with levofloxacin.
13. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
Q4H (every 4 hours) as needed.
Disp:*100 Lozenge(s)* Refills:*0*
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-8**] Sprays Nasal
QID (4 times a day).
Disp:*QS bottle* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
18. Saline Flush 0.9 % Syringe Sig: Three (3) ml Injection twice
a day for 20 doses: prior to each vanco dose.
Disp:*20 syringe* Refills:*0*
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
21. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain.
24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
26. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
27. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
28. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
29. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
30. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: for PICC line.
31. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1) Pulmonary Embolism with history of DVT and IVC filter
placement in [**2106-7-8**]
2) Community Acquired Pneumonia
3) History of GI Bleed (extensive) in [**2106-7-8**] when
anticoagulated
4) Abdominal wall hematoma, with acute blood loss anemia
requiring 10 units PRBCs when anticoagulated for current
pulmonary embolism
5) Noscomial Pneumonia with GNR in sputum,
6) Coagulopathy
7) Noscomial UTI with E. coli - quinolone resistant
8) Vagnitis, attributed to broad spectrum antibiotic usage
9) otitis externa
10) tachycardia
11) diarrhea
12) incidentally noted left renal cyst/mass NOS
13) Coagulase negative staphylococcal bacteremia
14) Rectus sheath hematoma in setting of anticoagulation
.
Secondary:
1) chronic orthostatic hypotension
2) recurrent otitis externa
3) ulcerative colitis in remission
4) chronic obstructive pulmonary disease
5) depression
6) h/o schizoaffective disorder
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed, please keep all
follow-up appointments. Please call your primary care doctor,
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **], or return to the Emergency Department if you
experience fevers, chills, worsening shortness of breath,
dizziness, lightheadedness, worsened chest pain, nausea,
vomiting, diarrhea, blood in your stools or any symptoms that
concern you.
.
Please take all of your medications as prescribed and follow up
with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
Followup Instructions:
You need to set up a followup appointment to see Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **]
in [**2-8**] weeks. Please call ([**Telephone/Fax (1) 39126**] to set up this
appointment.
.
You had the following appointment scheduled prior to your
hospitalization:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2107-1-28**] 1:00
***Follow up CT scan or ultrasound of left kidney is recommended
as well as Urologic follow up due to incidentally noted left
renal cyst/mass that may be malignant.*******
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2107-2-12**]
|
[
"556.9",
"728.89",
"053.9",
"V58.61",
"380.10",
"285.1",
"564.00",
"V12.51",
"295.70",
"793.2",
"112.1",
"E934.2",
"272.4",
"415.19",
"458.0",
"496",
"482.82",
"286.9",
"453.41",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"39.79",
"88.47",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
18008, 18087
|
7100, 14129
|
323, 331
|
19032, 19042
|
4183, 4183
|
19682, 20413
|
3377, 3582
|
14796, 17985
|
18108, 19011
|
14155, 14773
|
19066, 19659
|
3597, 4164
|
280, 285
|
359, 2015
|
4199, 7077
|
2037, 3040
|
3056, 3361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,804
| 180,943
|
54091
|
Discharge summary
|
report
|
Admission Date: [**2107-6-27**] Discharge Date: [**2107-7-6**]
Date of Birth: [**2044-2-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
[**2107-6-27**]
1. Minimally-invasive esophagectomy with intrathoracic
anastomosis.
2. Laparoscopic jejunostomy.
3. Buttressing of intrathoracic anastomosis with
pericardial fat.
4. Esophagogastroduodenoscopy .
History of Present Illness:
Mr. [**Known lastname 19219**] is a 63 year old male with a history of GERD and
Barrett's esophagus for which he was undergoing surveillance
endoscopy. He was found to have an adenocarcinoma within an
esophageal nodule near the GE junction. He underwent EUS on [**4-21**]
which noted a 1cm malignant appearing lesion at the GE junction
without evidence of invasion beyond the mucosal layer. A single
0.7 x 0.8 cm lymph node was seen in the periesophageal region
which was sampled via FNA. LN negative for malignancy. The
patient underwent endoscopic mucosal resection on [**2107-5-12**] with
pathology as low grade well to moderately differentiated
adenocarcinoma, at least intramucosal, multifocally extending to
specimen margins with concern for invasion, possibly into the
muscularis mucosae. He presents to discuss the possibility of
surgical resection.
Mr. [**Known lastname 19219**] explains that he had some mild heartburn in the past
but has difficulty remembering exactly when he was first started
on antacid medication. He reports having been followed with
serial endoscopy for at least 3-5 years for what sounds like
Barrett's esophagus likely found at the time of his initial GI
workup in the past. The cancer was diagnosed on recent
surveillance EGD.
The patient complains of a 15 pound weight loss and significant
anxiety which began upon learning his diagnosis. Otherwise he
denies reflux, dysphagia, odynophagia, heartburn, nausea,
shortness of breath, dyspnea on exertion, chest pain. Eating and
drinking well. Denies heart disease, MI, has never needed oxygen
therapy, never been hospitalized, never taken inhalers or
steroids for his lungs. He has a heavy smoking history, having
quit 2 weeks ago. Also a heavy drinking history, sober for last
20 years. The patient states that he hopes to have surgery as
soon as possible.
Past Medical History:
PAST MEDICAL HISTORY:
COPD, HTN, HTN, depression, tobacco use, hypercholesterolemia,
BPH, GERD
PAST SURGICAL HISTORY:
None
Social History:
Cigarettes: [ ] never [x} ex-smoker (quit 2 weeks ago) [ ]
current
Pack-yrs: 40 pack years
ETOH: [x ] No [ ] Yes drinks/day: prior heavy
drinker, sober 19 yrs
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation: retired truck driver
Marital Status: [ ] Married [x] Single
Lives: [ ] Alone [x} w/ family, accompanied today by
supportive niece
[**Name (NI) **] pertinent social history: does not exercise but states
that
he does a lot of walking, says does not get out of breath with 2
flights
________________________________________________________________
Family History:
Mother: colon cancer
Father
Siblings: brother lung cancer
Offspring
Other: aunt bladder cancer
Physical Exam:
Vital Signs sheet entries for [**2107-5-26**]:
BP: 117/73. Heart Rate: 78. Weight: 198.3. Height: 71.25. BMI:
27.5. Temperature: 97.5. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 98.
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2107-6-27**] 09:42AM GLUCOSE-180* LACTATE-1.1 NA+-138 K+-6.3*
CL--107
[**2107-6-27**] 09:42AM HGB-13.8* calcHCT-41
[**2107-6-27**] 10:43AM GLUCOSE-170* LACTATE-1.6 NA+-139 K+-6.4*
CL--108
[**2107-6-27**] 12:30PM GLUCOSE-190* UREA N-18 CREAT-0.9 SODIUM-139
POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-26 ANION GAP-8
[**2107-7-2**] Ba swallow :
Status post esophagectomy with gastric pull-through, without
evidence of holdup or leak at the neogastroesophageal junction
[**2107-7-3**] CXR :
The right-sided chest tube has been removed. Emphysematous
changes
in the lungs are again visualized. There is improved aeration
in the left
lower lung with decreased effusion; however, there continues to
be some
retrocardiac volume loss. Old rib fractures on the right are
again seen
Brief Hospital Course:
Mr. [**Known lastname 19219**] was admitted to the hospital and taken to the
Operating Room where he underwent a laparoscopic esophagectomy.
He tolerated the procedure well and returned to the PACU in
stable condition. He maintained stable hemodynamics and his
pain was well controlled with a thoracic epidural catheter. His
tube feedings were started via J tube on post op day #1 and he
was eventually cycled over 18 hours.
He was able to use his incentive spirometer effectively and his
oxygen was gradually weaned off with room air saturations of
94%. His epidural was removed and he was treated with oxycodone
for pain via the j tube.
A barium swallow was done on post op day #6 which confirmed no
anastomotic leak and he began a liquid diet which he tolerated
well. Unfortunately his J tube site started to leak some
purulent material and some erythema was noted around the tube.
The J tube was removed on [**2107-7-4**] and his diet was advanced to
soft solids along with Ensure supplements which he continued to
tolerate well.
The j tube site had a 1 cm area of cellulitis around the
insertion site and was I&D'd at the bedside with placement of a
wick. He was also placed on Keflex and the wound was monitored
for another 24 hours. The area receded a bit and he continued
to undergo [**Hospital1 **] dressing changes. He remained afebrile and his
pain at the J tube site decreased.
He was up and walking independently and continued to increase
his oral intake with soft food and supplements. He was
discharged to home on [**2107-7-6**] with VNA services and he will
follow up with Dr. [**First Name (STitle) **] in 1 week.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy.
1. Fluoxetine 60 mg PO DAILY
2. Omeprazole 40 mg PO BID
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Quetiapine extended-release 600 mg PO HS
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H pain
do not exceed 4 tabs in 24 hours
4. Cephalexin 500 mg PO Q6H
thru [**7-10**]
RX *cephalexin 500 mg 1 Tablet(s) by mouth four times a day Disp
#*20 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 5-10 mg PO Q3H:PRN pain
RX *oxycodone 5 mg [**1-10**] Tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO BID
10. Quetiapine extended-release 600 mg PO HS
11. Protein supplements
Ensure 1 can TID
disp 1 case
Refill 3 months
Dx esophageal cancer
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 Tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Esophageal cancer
J tube wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting
-Increased abdominal pain
-Incision develops increased drainage
J tube site
-Wick in place
-Change dressing twice daily and as needed with the help of VNA
-Call Dr. [**First Name (STitle) **] if the redness around the wound increases beyond
the purple mark
Pain
-Oxycodone as needed
-Take stool softners with narcotics
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Soft solids as tolerated with protein supplements ( 4 cans a
day)
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Danger signs
Fevers > 101 or chills
Increased shortness of breath, cough or chest pain
Incision develops drainage
Nausea, vomiting (take anti-nausea medication)
Increased abdominal pain
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2107-7-12**] 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:[**2107-7-6**]
|
[
"401.9",
"293.0",
"530.85",
"070.54",
"569.61",
"496",
"151.0",
"600.00",
"682.2",
"V15.82",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"46.39",
"42.41",
"96.6",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
8931, 8989
|
6104, 7748
|
282, 503
|
9074, 9074
|
5295, 6081
|
10507, 11023
|
3195, 3292
|
8120, 8908
|
9010, 9053
|
7774, 8097
|
9225, 10484
|
2519, 2526
|
3307, 5276
|
233, 244
|
531, 2378
|
9089, 9201
|
2422, 2496
|
3005, 3179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,697
| 149,872
|
26081+57488
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-1-27**] Discharge Date: [**2200-2-6**]
Service: VSU
CHIEF COMPLAINT: Left leg ischemia.
HISTORY OF PRESENT ILLNESS: This is an 89-year-old white
female who was admitted for an axillo-bifemoral bypass graft
secondary to left leg ischemic changes. The patient could not
ambulate any more than 20 feet. She complained of bilateral
leg weakness with ambulation, left greater than right, and
she did admit to rest pain.
REVIEW OF SYMPTOMS: Negative for diabetes or thyroid
disease. She does have voice raspiness, and this is secondary
to traumatic intubation 1 year ago. She denies peptic ulcer
disease, melena, bloody stools, kidney stones and liver
disease. She does have a history of angina. She has
palpitations occasionally. Heart murmur. She denies
myocardial infarction or congestive heart failure. She denies
fever, chills or sweats. She denies CVA, TIA, seizures and
amaurosis.
Preoperative ultrasound of the carotids demonstrated less
than 40% bilateral internal and external coronary artery
disease. The patient's MRA, done secondary to her renal
insufficiency, showed a right common iliac stenosis with
plaque. The left common iliac was stenosed. The right SFA and
PFA was diseased. The collaterals to the knee and popliteal
is with runoff via the peroneal and PT. On the left, the
common femoral artery had diseased SFA and PFA, occluded, but
reconstructed from collaterals from the PFA. The popliteal
was with severe disease. The dominant runoff vessel of the
left foot was the posterior tibial vessel. The patient denies
any interval change since last seen.
ALLERGIES: Heparin, CPR, does not recall actual
manifestation of allergy. Aspirin causes GI upset. Nevarcone;
the patient is not aware of the medication or any allergies.
Nitroglycerin disk; denies any allergies, although it is
indicated on her medical history.
MEDICATIONS ON ADMISSION: Potassium 20 mEq q.48 hours,
enalapril 10 mg daily, Lopressor 50 mg b.i.d., Lexapro 10 mg
daily, Lasix 10 mg daily, Lipitor 20 mg daily, Combivent
multidose inhaler q.i.d. p.r.n., Tylenol p.r.n.
PAST MEDICAL HISTORY: Peripheral vascular disease,
hypertension, hypercholesterolemia, bilateral cataract status
post excision and lens replacement, history of toxic shock
secondary to pneumonia requiring intubation, history of
coronary artery disease, history of GERD.
PAST SURGICAL HISTORY: Left meniscectomy, bilateral cataract
surgery, vertebroplasty secondary to compression fractures in
[**2198**], angioplasty of coronary arteries with stenting x 2,
artery done not known; this was done at [**Hospital 64726**] Hospital in
[**2199**]. Her cardiologist is Dr. [**Last Name (STitle) **] in [**Location (un) 976**] [**State 350**].
The patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**],
[**Telephone/Fax (1) 64727**].
SOCIAL HISTORY: The patient lives alone and uses assist
device with ambulation. She has not smoked for 30 years. She
uses alcohol rarely.
PHYSICAL EXAMINATION: Vital signs: Blood pressure in the
right arm was 180/60, left arm 118/80. HEENT: No JVD.
Carotids 1+, palpable pulses bilaterally. The left carotid is
with a bruit which radiates to the subclavian. The thyroid is
not enlarged. Lungs: Clear to auscultation bilaterally.
Heart: Regular rate and rhythm with a 3/6 systolic ejection
murmur at the base which radiates to the apex. Abdomen: Soft,
nontender, nondistended, protuberant. Bowel sounds are quiet
x 4. There are no bruits or masses. Extremities: Peripheral
vascular exam shows the left toe with ruborous cyanosis which
extends to the dorsum of the foot and the temperature of the
toes were cool. On the right, there is a femoral bruit. Pulse
exam shows palpable brachial and radial arteries at 1+,
femorals are 1+ and palpable. The DP and PT are Doppler
signals on the right and absent on the left. Neurologic: The
patient is oriented times 3 and nonfocal.
HOSPITAL COURSE: The patient was admitted to the vascular
service. She was prepared for surgery. She underwent, on
[**2200-1-28**], a right axillo-bifemoral bypass graft. She
tolerated the procedure well. The patient remained stable in
the PACU and was transferred to the intensive care unit
secondary to requiring argatroban for anticoagulation
postoperatively. The patient was continued on cefazolin. Swan
remained in place. The patient had some prominent pulmonary
congestion. The patient did have hypotension postoperatively.
A repeat echocardiogram was done which showed significant
aortic stenosis but no changes in the left ventricular
function.
Her diet was advanced as tolerated. She was noted to have a
decreased platelet count which was serially monitored. She
also required transfusion of 1 unit of packed red blood cells
for a postoperative hematocrit of 29.2. EKGs were without
changes. The CK and MBs were flat. Posttransfusion hematocrit
was 28.2.
ambulation was begun on postoperative day 2. She was begun on
clear fluids. The Swan was converted to CVP. Coumadin was
started.
The patient had an episode of waxing and [**Doctor Last Name 688**] mental status
changes on postoperative day 3 and an episode of SVT at a
rate of 140 which responded to IV Lopressor. Chest x-ray
showed probably congestive heart failure. She continued on IV
Lasix drip with improvement in her respiratory status.
On postoperative day 4, the patient became mildly
hypotensive, and the Lasix was discontinued. The patient had
no further episodes of SVT. Her hematocrit remained stable at
27.3, BUN 14, creatinine 0.9. The graft was palpable. Feet
were warm.
The patient was placed on aspiration precautions. Her HIT was
negative, and there was slow return on her platelet count.
The patient was transferred to the VICU for continued
monitoring and care. On postoperative day 5, the patient
continued to diurese. She tolerated her p.o. intake.
Incisions were clean, dry and intact. Pulse exam remained
unchanged. Ambulation was continued. Physical therapy
evaluated the patient and felt that she would benefit from
rehab, since she was not safe to be discharged to home.
The patient continued on a heparin-to-Warfarin transition.
The arterial line was discontinued on postoperative day 6.
Chest x-ray showed continued improvement. On postoperative
day 7, she continued to progress and remained afebrile.
Geriatric service was consulted secondary to postoperative
delirium. The patient's left heel revealed some stage I
decubitus changes, and a waffle boot was applied to the foot
for off-loading.
On postoperative day 8, the patient had CKs drawn for
questionable angina but so far have been flat. Troponins have
been flat. EKGs have been without significant change.
The patient will be discharged to rehab when medically
stable.
DISCHARGE MEDICATIONS: Albuterol/ipratropium aerosol 1-2
puffs q.6 hours as needed, ipratropium bromide 0.02% solution
inhalation q.2-3 hours if needed for dyspnea, albuterol
sulfate solution inhalation q.2-3 hours if needed,
acetaminophen/codeine 300/30 mg tablets [**11-25**] q.4 hours p.r.n.
as needed, acetazolamide 250 mg q.6 hours, Lopressor 25 mg
b.i.d., Protonix 40 mg daily, Diltiazem 60 mg q.i.d.,
Dulcolax tablets 2 p.r.n., Colace 100 mg b.i.d., senna
tablets 8.6 mg 1 b.i.d., atorvastatin 10 mg daily, warfarin 2
mg daily.
DISCHARGE INSTRUCTIONS: The patient should followup with her
primary care physician for regular monitoring of her INR.
This was started for graft patency. The goal INR is 2.0-3.0.
This should be monitored at rehab and again by her primary
care physician upon discharge from rehab. The patient may
shower but no tub baths. No lifting greater than 2 lb for a
total of 6 weeks. No overhead trapezius on the bed. No
hyperextension of right arm. Continue all medications as
directed. Continue to take stool softener while taking pain
medication.
DISCHARGE DIAGNOSIS:
1. Left leg ischemia.
2. History of hypertension.
3. History of hypercholesterolemia.
4. History of ischemic heart disease status post
percutaneous transluminal angioplasty of coronary artery
with stenting x 2.
5. History of carotid disease with bilateral carotid
disease, external and internal, asymptomatic.
6. History of lumbosacral fracture status post
vertebroplasty.
7. History of cataract, status post bilateral cataract
surgery.
8. Postoperative blood loss anemia, transfused.
9. Postoperative congestive heart failure, systolic,
compensated.
FOLLOW UP: The patient should followup with Dr. [**Last Name (STitle) 1391**] in
2 weeks' time; call for an appointment at [**Telephone/Fax (1) 1393**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2200-2-5**] 12:01:21
T: [**2200-2-5**] 12:50:36
Job#: [**Job Number 64728**]
Name: [**Known lastname 11465**],[**Known firstname 11466**] Unit No: [**Numeric Identifier 11467**]
Admission Date: [**2200-1-27**] Discharge Date: [**2200-2-7**]
Date of Birth: [**2110-5-17**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2200-2-6**] Patient has been noted to have recurrent SOb on arrising
in Am but afterward and remaing of the day is without SOB.
Repeat cxr has been negative for CHF. Echo [**2200-1-28**] showed aortic
valve area of 0.08cm2, ( moderate stenosis ) with mild AI EF
50-55%. Patient awaiting screening for rehab.
[**2200-2-7**] stable. No SOB this am. excellent result from bowel
regment. D/c to rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital 11468**] Hospital TCU
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2200-2-7**]
|
[
"424.1",
"427.1",
"V45.82",
"287.5",
"458.29",
"514",
"593.9",
"440.23",
"707.07",
"428.21",
"285.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.04",
"39.29",
"99.05",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
9705, 9937
|
6846, 7359
|
7923, 8508
|
1902, 2098
|
4007, 6822
|
7384, 7902
|
2394, 2913
|
8520, 9682
|
3076, 3989
|
106, 126
|
155, 1875
|
2121, 2370
|
2930, 3053
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,519
| 170,597
|
34489
|
Discharge summary
|
report
|
Admission Date: [**2182-4-24**] Discharge Date: [**2182-5-3**]
Date of Birth: [**2109-7-1**] Sex: M
Service: SURGERY
Allergies:
Methotrexate / Imuran / Remicade
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Chronic medically refractory ulcerative colitis.
Major Surgical or Invasive Procedure:
Total abdominal colectomy ileostomy Hartmann pouch.
History of Present Illness:
This very sick gentleman with thrombocytopenia
would be on high dose of steroids with multiple opportunistic
infections presented with medically refractory ulcerative
colitis had been cancelled several times owing to active co-
morbidities.
Past Medical History:
UC since [**2172**], in remission until last year, had Imuran and
Remicade trial in the past, of Imuran and MTX since [**Month (only) 216**] and
Of Remicade sice [**Month (only) 116**] due to intolerance, and on chronic
prednisone 30 mg, last dose this am, no pcp prophylaxis,
DM type 2
HTN
HC
Possible silent MI, cath and Echo in [**Month (only) 404**], no stenting, not
on Aspirin due to low platelets, no bleeding history
h/o prostatitis
Social History:
30 years 1 ppd smoking stopped 14 years ago, alcohol couple
times a month, lives with wife near [**Name2 (NI) **], retired school
superintendent
Family History:
N/C
Physical Exam:
At discharge:
V.S: 98.8, 78, 109/24, 20, 99% RA
Gen: a and o x3, NAD
CV: rrr, no m/r/g
Resp: LSCTA Bilat, no w/r
Abd: soft, tender at incision site, nd, stoma beefy red.
Incision: OTA with staples
Ext: no c/c/e
Pertinent Results:
[**2182-4-30**] 04:15AM BLOOD WBC-3.5*# RBC-3.02* Hgb-10.3* Hct-29.7*
MCV-98 MCH-34.2* MCHC-34.8 RDW-22.4* Plt Ct-30*
[**2182-4-28**] 10:36AM BLOOD Neuts-62.4 Lymphs-35.2 Monos-1.8* Eos-0.4
Baso-0.3
[**2182-4-24**] 06:11PM BLOOD Hypochr-1+ Anisocy-3+ Poiklo-OCCASIONAL
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
[**2182-4-30**] 04:15AM BLOOD Plt Ct-30* LPlt-2+
[**2182-5-1**] 06:10AM BLOOD Glucose-117* UreaN-10 Creat-0.5 Na-138
K-3.8 Cl-102 HCO3-28 AnGap-12
[**2182-4-30**] 08:01PM BLOOD CK(CPK)-8*
[**2182-5-1**] 06:10AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8
[**2182-4-30**] 08:01PM BLOOD CK-MB-3 cTropnT-<0.01
[**2182-4-25**] 09:55PM BLOOD VitB12-723 Folate-10.4
[**2182-4-28**] 11:03AM BLOOD Prblm-[**Doctor First Name **] @
[**2182-4-28**] 11:00AM BLOOD Type-ART pO2-203* pCO2-39 pH-7.51*
calTCO2-32* Base XS-7
[**2182-4-28**] 11:00AM BLOOD Lactate-1.8 Na-129* K-3.7 Cl-94*
[**2182-4-24**] 04:39PM BLOOD Hgb-8.0* calcHCT-24
[**2182-4-24**] 04:39PM BLOOD freeCa-1.03*
.
Echo [**4-30**]
Suboptimal image quality. Regional systolic dysfunction
consistent with prior myocardial infarction. Right ventricular
dilation and dysfunction. Mild aortic regurgitation.
.
CXR [**4-28**]
In comparison with the study of [**4-26**], there are slightly lower
lung
volumes. Persistent bibasilar atelectasis without acute
pneumonia. The
pulmonary vessels are slightly less well seen, raising the
possibility of some increasing pulmonary venous pressure.
There has been interval placement of a right IJ catheter that
appears to turn towards the midline and extend into the left
brachiocephalic vein.
Brief Hospital Course:
72 year-old male with a history of refractory UC on chronic
prednisone, s/p total abdominal colectomy with end ileostomy
[**4-24**] with post op MICU monitoring for extubation. Pt was
transferred to [**Hospital Ward Name **] 5. On the surgical floor, the patient
had been advanced to tolerating regular diet, and was seen by
heme onc for evaluation of pancytopenia with working diagnosis
of MDS. Patient was doing well until [**4-28**], when after being
given first dose of beta blocker at 9am (Carvedilol 6.25mg PO)
patient was found approxmimately 2 hours later, somnolent and
difficult to arouse. BP was unable to be easily obtained at the
bedside so a code blue was called. Upon arrival of the code
team, the patient was arousable and responding to commands. BP
placed on the leg registered 67/47. O2 sat was 100% on 2L NC.
Patient was in sinus bradycardia, with rates in the 40s. Pt. was
very nervous but denied chest pain, SOB, abd. pain. He had also
received 20mg IV of lasix earlier in the day. He was than
transferred back to MICU after code blue on [**Hospital Ward Name **] 5 for
hypotension, bradycardia, and decreased mental status.
.
On arrival to MICU, patient was alert, conversant, anxious but
able to consent to procedures, and denying abdominal pain, chest
pain, shortness of breath, or lightheadedness. Patient's BP on
arrival was 59/43, started on Levophed and given fluids with
response in SBP to 116/82. Hct 23.2 down from baseline of 27,
platelets 35, recent INR 1.3, with no evidence of active
bleeding. Patient with only single lumen right PICC for access
so emergent RIJ triple lumen central line was successfully
placed for access and CVP monitoring.
.
The patient returned to [**Location **] five. The ostomy RN and [**Name8 (MD) **]
RN provided teaching to patient and wife regarding ostomy care
and assessment. VNA will follow at home and provide further
teaching.
.
Cardiology was consulted for hypotension and bradycardia. This
was most likely secondary to meds. No [**Last Name (un) **] elevation. EF 40%
unchanged. He was started on lopressor 12.5 TID and will follow
up with cardiology. An appointment was made with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 79246**] on [**5-9**] at 12:30.
.
The patient complained of ear pain x1 month. He stated he saw a
ENT doctor and both ears were "cleaned out" in [**Month (only) 958**]. His ENT
doctor stated his hears were "fine" however he still c/o of a
throbbing pain. The patient stated he did not want to make an
appointment with an ENT doctor [**First Name (Titles) **] [**Last Name (Titles) 18**] and that he will follow
up with a new ENT closer to home. The patient's ear was examined
and it was with in normal limits.
.
He was seen by physical therapy and they recommended that the
patient be d/c'd with home physical therapy. He would like to
have his hematologist preform the bone marrow biopsy so he will
follow up with Dr. [**Last Name (STitle) **] in one week. I touched base with Dr.
[**Last Name (STitle) **] and he would like the patient to call and make an
appointment once he gets home. He will follow up with his PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 79247**] [**Name (STitle) **] on [**5-9**] at 2:40 and Dr. [**Last Name (STitle) **] on [**5-13**]. The
discharge summary was sent to his PCP, [**Name10 (NameIs) 2085**] and
hematologist. Education on prednisone teaching was provided. All
questions were answered and patient with call with questions or
concerns.
Medications on Admission:
Simvastatin 40', Coreg 6.25'', Flomax 0.4', Prednisone 15',
Insulin, Lantus 20U qhs, Lisinopril 5', Finasteride 5'
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
6. Prednisone 5 mg Tablet Sig: as directed Tablet PO twice a
day: [**Date range (1) 17717**]: 7.5mg qAM & 5.0mg qPM
[**Date range (1) **]: 5.0mg qAM & 5.0mg qPM
[**Date range (1) 58651**]: 5.0mg qAM & 2.5mg qPM
[**5-14**]- [**5-16**]: 2.5mg qAM & 2.5mg qPM
[**Date range (1) 16935**]: 2.5mg qAM & 0mg qPM
.
Disp:*50 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lantus 100 unit/mL Solution Sig: Twenty (20) Units
Subcutaneous QHS.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
Primary:
Chronic medically refractory ulcerative colitis
Pancytopenia
Anemia
Post-op hypotension
Post-op bradycardia
Post-op decreased mental status
.
Secondary:
UC '[**72**], in remission until last year, had Imuran and
Remicade trial in the past, of Imuran and MTX since [**Month (only) 216**] and
Of Remicade sice [**Month (only) 116**] due to intolerance, and on chronic
prednisone 30 mg, last dose this am, no pcp prophylaxis, DM type
2
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment.
-Steri-strips will be applied and they will fall off on their
own. Please remove any remaining strips 7-10 days after
application.
-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.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours
.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 9**], on [**5-13**]. Please call the office for a time.
2. Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 79248**], on
[**5-9**] at 2:40.
3. Please follow up with your Hematologist Dr. [**Last Name (STitle) **],
[**Telephone/Fax (1) 79249**], to make an appointment to have a bone marrow
biopsy in [**1-11**] weeks
4. Please follow up with your Cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79246**],
[**Telephone/Fax (1) 79250**], on [**5-9**] at 12:30.
5. Please follow up with your ENT doctor to make a follow up
appointment regarding your ear pain.
Completed by:[**2182-5-6**]
|
[
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"780.97",
"272.4",
"428.0",
"V45.82",
"556.9",
"427.1",
"287.5",
"427.89",
"412",
"458.29",
"238.75",
"414.01",
"784.0",
"388.70",
"276.52",
"401.9",
"V58.67",
"285.9",
"284.1",
"250.00",
"518.81",
"E941.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"46.20",
"45.82"
] |
icd9pcs
|
[
[
[]
]
] |
7822, 7878
|
3182, 6691
|
337, 391
|
8364, 8443
|
1557, 3159
|
10353, 11112
|
1306, 1311
|
6857, 7799
|
7899, 8343
|
6717, 6834
|
8467, 9505
|
9520, 10330
|
1326, 1326
|
1340, 1538
|
248, 299
|
419, 662
|
684, 1126
|
1142, 1290
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,009
| 190,619
|
45162
|
Discharge summary
|
report
|
Admission Date: [**2192-3-31**] Discharge Date: [**2192-4-2**]
Date of Birth: [**2112-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Abdominal distension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y/o M w/ baseline dementia, ESRD on HD, recurrent E coli
bacteremia of unclear source, recurrent prostatitis w/ possible
abscess, who p/w altered mental status, recent swallowing
difficulties, increasing abdominal distention, and brown thick
discharge from his penis.
.
In the ED, Labs showed normal WBC w/ left shift and floridly
positive U/A. ECG had question of lateral ST depressions.
Tropinin was below normal baseline. He had a CT abdomen
performed which showed distended stool loaded colon with
fecalization of the distal
small bowel. He received 1 dose of ceftriaxone. Also while in
the ED, he became agitated and received 2 mg of haldol w/
improved agitation. While awaiting transport to the floor, he
became hypertensive w/ SBPs in 190s and required IV hydralazine
with improvement to 140s.
.
He has had a [**Hospital 96531**] medical course of late w/ recurrent
hospital admissions for E coli bacteremia and prostatitis c/b
recurrent foley trauma. He was intitially admitted in [**1-23**] after
blood cultures drawn at HD grew E coli. During admission he was
also noted to have penile discharge. Since that time he has had
3 subsequent admissions for recurrent penile discharge and
bacteremia w/ E coli. He has undergone extensive work up for
both including CT abdomen/pelvis showing possible prostatic
abscess, TTE showing possible aortic valve vegetation(which was
not seen on subsequent TTE and wife refused [**Name2 (NI) **]), normal
colonscopy, CT cystogram negative for enterovesicular fistula,
and retrograde uretogram showing a large
hollowed out section of the prostate which may represent abscess
or fistula. He has completed multiple prolonged courses of
antibiotics under the guidance of ID and Urology consultations.
Following his last admission for the above problems in [**5-23**], he
completed a course of Zosyn in house and then followed up with
Urology as an outpt after which he was placed on Macrodantin x 3
months. He was most recently admitted [**Date range (1) 96532**]/08 for recurrent
seroma over dialysis access site in his R arm. He had recently
underwent a revision of the graft secondary to a large seroma.
He had excision of right upper arm arteriovenous graft [**2192-2-22**]
and a temporary HD line was placed and was scheduled for
permanent line placement by IR post-discharge. In addition,
blood cultures from presentation grew clostridium species.
However, subsequent blood cultures were negative. Wound cultures
from seroma also grew vanco sensitive enterococcus. He competed
a 14 day course of vanco and ceftazidime.
Past Medical History:
# ESRD related to HTN nephropathy s/p av graft in both arms, R
arm was functional until the past 24h
# HTN x >20 yrs
# Multivascular dementia
# BPH
# Chronic LBP with DJD, spinal stenosis
# Macrocytic anemia, unclear etiology
# h/o Bacteremia: [**12-22**]- Ecoli,B. Fragilis; [**3-23**] - Ecoli;
several Ecoli isolates w/ different sensitivities
- [**2191-4-4**] TTE: no vegetation seen.([**Month/Day/Year **] again refused)
- [**2191-3-26**] TTE: aortic valve echodensity is new and c/w possible
vegetation (wife and pt refused [**Month/Day/Year **]) but completed 4 wks of
ceftazidime
- outpt colonoscopy normal [**1-23**] w/o evidence of infectious
source
- CT [**12-23**] w/ hypodensity in prostate
.
# Prostatitis - multiple admissions w/ penile discharge, UTI,
prostatitis
- readmission [**5-/2191**]: w/ penile discharge
---CT cysto gram neg for enterovesicular fistula
---Retrograde uretogram was performed and showed a large
hollowed out section of the prostate which may represent abscess
or fistula.
--- tx'ed w/ Zosyn x 7 days
- readmission [**Date range (1) 96533**]: hematuria
- [**Date range (1) 96534**]/07: recurrent discharge w/ Ecoli bacteremia
---prostate MRI: cannot exclude abscess-> 4wks ceftazidime
---Daily bladder irrigation through the Foley with fluid
containing
Neomycin-Polymyxin
--- cytoscopy w/ purlent drainage from bladder
--- d/c on 4 wks ceftazidime
- [**1-23**]: penile discharge noted following foley catheter removal
- [**12-22**]: CT of prostate with hypodense area: per Urology, not
concerning for abscess when compared to prior imaging -> 4 wk
course of Cipro/Flagyl
Social History:
Lives w/ wife in [**Location (un) 686**]. Retired plumber; no tob, etoh or
drugs;
Family History:
NC
Physical Exam:
Admission PE:
VS: 98.6, 136/72, 95, 98% RA
Gen: Responds briefly to questions, directs eyes appropriately,
moves to command occasionally
HEENT: No conjunctival pallor. No icterus. MMM. Will not open
mouth for OP exam.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: Grossly distended, firm, tense, no tenderness to palpation
throughout, hypoactive bowel sounds, tympanitic
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: Will not answer A&O questions. Will not cooperate with
motor exam. States yes to sensation questions.
.
MICU transfer PE:
T: 99.4 BP: 91/53 HR:74 RR: 30 O2 99% bipap
Gen: elderly man, opens eyes to stimulus
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: Distant. RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: Distended, firm, NT, no bowel sounds
EXT: WWP, NO CCE. 2+ DP pulses BL, fistula s/p surgical removal
SKIN: No rashes/lesions, ecchymoses.
NEURO: Moves all fours, opens eyes, Gait assessment deferred
Pertinent Results:
CT abdomen/pelvis [**3-30**]:
The lung bases are clear aside from mild bibasilar atelectasis.
The heart is enlarged. A central venous catheter is partially
visualized terminating in the cavoatrial junction. There are
aortic valvular calcifications. Allowing for the limitations of
a non-contrast
study, the liver, pancreas, spleen, stomach, adrenal glands, and
small bowel loops are normal. Multiple small layering
stone/sludge present in an otherwise normal-appearing
gallbladder. The kidneys are small and atrophic, containing
multiple small probable cysts consistent with history of
end-stage renal disease. There is no free air or free fluid.
CT PELVIS WITH CONTRAST: The entire colon is markedly distended
with stool including fecalization of the distal small bowel. The
prostate is enlarged. The bladder appears normal. There is no
free air, free fluid, or pathologic adenopathy.
BONE WINDOWS: There are multilevel degenerative changes, but no
suspicious lesions.
IMPRESSION: Distended stool loaded colon with fecalization of
the distal small bowel.
.
[**4-1**] KUB: The cecum and ascending colon are dilated, measuring
up to 10.1 cm. Specks of radiodense material are present within
the colon, which represent dense residual contrast from prior
administration. Small bowel does not appear to be dilated. There
is no supine evidence of free intraperitoneal air. Upper abdomen
is excluded from the radiograph. The osseous structures are
diffusely demineralized.
IMPRESSION: Persistent colonic dilatation, unchanged from scout
images of recent CT.
.
[**2192-3-31**] 09:20AM GLUCOSE-86 UREA N-47* CREAT-11.0* SODIUM-142
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-22*
[**2192-3-31**] 09:20AM CK(CPK)-104
[**2192-3-31**] 09:20AM CK-MB-7 cTropnT-0.19*
[**2192-3-31**] 09:20AM CALCIUM-9.8 PHOSPHATE-5.2* MAGNESIUM-2.3
[**2192-3-31**] 09:20AM WBC-6.6 RBC-3.33* HGB-11.9* HCT-39.0*
MCV-117* MCH-35.7* MCHC-30.5* RDW-16.9*
[**2192-3-31**] 09:20AM PLT COUNT-170
[**2192-3-31**] 01:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2192-3-31**] 01:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2192-3-31**] 01:30AM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-<1
[**2192-3-31**] 01:30AM URINE AMORPH-MANY
[**2192-3-31**] 01:30AM URINE MUCOUS-MANY
[**2192-3-30**] 08:30PM GLUCOSE-119* UREA N-40* CREAT-10.3*#
SODIUM-142 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-27 ANION GAP-22*
[**2192-3-30**] 08:30PM estGFR-Using this
[**2192-3-30**] 08:30PM ALT(SGPT)-21 AST(SGOT)-48* LD(LDH)-239 TOT
BILI-0.3
[**2192-3-30**] 08:30PM CK-MB-7 cTropnT-0.19*
[**2192-3-30**] 08:30PM ALBUMIN-4.9*
[**2192-3-30**] 08:30PM NEUTS-78.7* LYMPHS-13.0* MONOS-6.1 EOS-1.8
BASOS-0.3
[**2192-3-30**] 08:30PM PLT COUNT-193
[**2192-4-1**] 07:05AM BLOOD WBC-11.5*# RBC-3.45* Hgb-13.0* Hct-42.0
MCV-122* MCH-37.7* MCHC-31.0 RDW-16.7* Plt Ct-202
[**2192-4-1**] 05:47PM BLOOD WBC-9.1 RBC-3.24* Hgb-12.1* Hct-38.0*
MCV-118* MCH-37.4* MCHC-31.8 RDW-16.9* Plt Ct-201
[**2192-4-2**] 01:43AM BLOOD WBC-7.8 RBC-3.12* Hgb-11.8* Hct-36.4*
MCV-117* MCH-37.8* MCHC-32.4 RDW-17.0* Plt Ct-171
[**2192-4-1**] 07:05AM BLOOD Glucose-98 UreaN-45* Creat-9.5*# Na-146*
K-4.1 Cl-98 HCO3-16* AnGap-36*
[**2192-4-1**] 05:47PM BLOOD Glucose-143* UreaN-64* Creat-10.8*#
Na-142 K-4.1 Cl-98 HCO3-20* AnGap-28*
[**2192-4-2**] 01:43AM BLOOD Glucose-110* UreaN-72* Creat-11.0* Na-145
K-3.8 Cl-102 HCO3-17* AnGap-30*
[**2192-4-1**] 05:47PM BLOOD ALT-91* AST-233* LD(LDH)-316*
CK(CPK)-2695* AlkPhos-91 Amylase-119* TotBili-0.4
[**2192-4-2**] 01:43AM BLOOD ALT-107* AST-282* LD(LDH)-376*
CK(CPK)-3502* AlkPhos-92 Amylase-104* TotBili-0.4
[**2192-4-2**] 10:07AM BLOOD CK(CPK)-3291*
Brief Hospital Course:
80 M with dementia, HTN, ESRD on HD, recurrent Ecoli bacteremia,
prostate abscess, admitted with confusion, abdominal distension,
difficulty swallowing, copious purulent penile discharge.
.
Brief hospital course:
Patient was initially admitted to the floor and placed on
aggressive bowel regimen and urology was consulted. Plan was
for protate US to look for prostatic ascess. On [**4-1**] while on
the floor the patient developed hypotension and an acute change
in mental status. Pt was non-verbal with verbal baseline. MICU
evaluation revealed :ABG 7.23/54/82 with lactate 3.6. SBP was 84
with HR in the 70s. He appeared tachypneic. He received 500cc NS
as well as vancomycin, flagyl, Zosyn. He was transferred to the
MICU with a diagnosis of septic shock
EKG was unchanged from prior. Labs returned with CK of 2600.
Surgery was consulted. Of note patient was unable to complete
dialysis (0.5L off) the day prior to transfer secondary to
hypotension. Possible sources of infection included GU tract
given purulent penile discharge on admission or abdominal source
given distention and colonic dilitation seen on plain films. He
was aggressively hydated with IVF and continued on broad
spectrum antibiotics including Vanco, Zosyn, and Flagyl.
Bladder irrigation with Neomycin-Polymyxin was also continued.
A CVL was attemped x2 without ability to thread the wire and was
aborted. Given the abdominal distention surgery was consulted
for concern for ischemic colitis. An exploratory laparotomy was
offered to the patient's wife who declined surgical
intervention. An NG tube was placed for decompression. Over
the course of the next 24 hours in the ICU the patient's
condition continued to worsen with progressive hypotension and
the patient became unresponsive. His critical and deteriorating
condition was discussed with his family who did not want to
continue aggressive intervention. The decision was made to make
the patient CMO on the morning of [**4-2**]. Antibiotics were
discontinued and the patient expired at 2:20pm on [**4-2**] with his
family at the bedside. His wife declined a post-mortem exam.
Medications on Admission:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
[**Hospital1 **] (2 times a day) as needed for back pain.
Disp:*35 Tablet(s)* Refills:*0*
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DINNER
.
Medications on transfer to ICU:
1. IV access: Peripheral Order date: [**3-31**] @ 0643 9.
MetRONIDAZOLE (FLagyl) 500 mg IV Q12H Order date: [**4-1**] @ 1601
2. 500 mL NS Bolus 500 ml Over 20 mins Order date: [**4-1**] @ 1522
10. Piperacillin-Tazobactam Na 2.25 g IV Q12H *Awaiting ID
Approval* Order date: [**4-1**] @ 1455
3. Amlodipine 7.5 mg PO DAILY Order date: [**3-31**] @ [**2190**]
11. Piperacillin-Tazobactam Na 2.25 g IV ONCE Duration: 1 Doses
Start: [**2192-4-1**] Order date: [**4-1**] @ 1526
4. Cinacalcet HCl 30 mg PO Q DINNER Order date: [**3-31**] @ [**2190**]
12. Simethicone 120 mg PO QID Order date: [**3-31**] @ 2034
5. Fleet Phospho-Soda 45 ml NG ONCE Duration: 1 Doses
Please give by rectum. Order date: [**3-31**] @ 2230
13. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift Order date: [**3-31**] @
0643
6. Lanthanum 500 mg PO TID W/MEALS Order date: [**3-31**] @ [**2190**]
14. Vancomycin 1000 mg IV HD PROTOCOL
ID Approval will be required for this order in 71 hours. Order
date: [**4-1**] @ 1455
7. Lactulose 30 mL PO TID Order date: [**3-31**] @ 2034
15. Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date:
[**4-1**] @ 1523
8. Metoprolol 12.5 mg PO BID Order date: [**3-31**] @ [**2190**]
(Dinner).
6. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"518.81",
"038.9",
"785.52",
"410.91",
"601.2",
"585.6",
"564.7",
"403.91",
"437.0",
"V66.7",
"599.0",
"290.41",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13703, 13712
|
9887, 11797
|
335, 341
|
13763, 13772
|
5907, 9650
|
13824, 13956
|
4690, 4694
|
13675, 13680
|
13733, 13742
|
11823, 13652
|
13796, 13801
|
4709, 5888
|
275, 297
|
369, 2939
|
2961, 4574
|
4590, 4674
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,150
| 155,910
|
52173
|
Discharge summary
|
report
|
Admission Date: [**2167-2-6**] Discharge Date: [**2167-2-20**]
Date of Birth: [**2092-2-13**] Sex: M
Service: [**Known lastname **] SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 74-year-old
male sent to the [**Hospital1 18**] from [**Hospital3 4419**] Hospital
when he was noted to have an increasing white count to
16,000, a drop in his systolic blood pressure to the 60s,
distention of the abdomen with decreased bowel sounds. The
patient was sent to the medical center for evaluation of his
abdomen.
At the rehabilitation hospital, the patient had been noted to
be incontinent of loose watery diarrhea and was also noted to
have a sore on his scrotum.
The patient had been discharged to [**Hospital3 4419**]
Hospital from the [**Hospital1 18**] following an admission from [**2166-12-29**]
to [**2167-1-12**]. The patient had been admitted to the [**Hospital1 18**] for
a right partial nephrectomy for a right kidney mass. Please
refer to the previously dictated discharge summary for the
[**Hospital 228**] hospital course during that admission following the
surgery.
In the MICU, the [**Hospital 228**] hospital course during that
admission, was complicated by a myocardial infarction,
pneumonia caused by MRSA, a failed swallow study requiring
the placement of a PEG tube.
PAST MEDICAL HISTORY:
1. Renal cell carcinoma, status post partial nephrectomy in
[**12-22**].
2. IDM.
3. Hypertension.
4. Neuropathy.
5. MRSA positive.
6. Prostate cancer.
ADMISSION MEDICATIONS:
1. Lantus 46 units.
2. Zocor 20 mg per day.
3. Lopressor 37.5 mg b.i.d.
4. Zestril 10 mg q.d.
5. Aspirin 81 mg p.o. q.d.
6. Protonix 40 mg p.o. q.d.
7. Neurontin 300 mg p.o. q.i.d.
8. Paxil 10 mg p.o. q.d.
9. Ativan.
10. Loperamide.
ALLERGIES: Penicillin.
SOCIAL HISTORY: No alcohol. The patient quit smoking
tobacco 60 years ago. The patient is a former lawyer with
three children. The patient is reported to have had home
assistance for activities of daily living.
PHYSICAL EXAMINATION ON ADMISSION: On arrival, the patient
had a temperature of 98, blood pressure 92/55, heart rate 69,
respiratory rate 21, and oxygen saturation of 96%. The
patient appeared in no apparent distress with a flattened
affect. The physical examination was notable for a tense and
distended abdomen which was tender to moderate palpation
throughout. The patient was noted to have an area of
gangrenous skin on the dorsum of his right scrotum with
bilateral scrotal erythema and edema.
LABORATORY DATA ON ADMISSION: The patient had a white count
of 18 with 71% neutrophils, 18% lymphocytes, 8% monocytes,
and a hematocrit of 9.6. The patient's Chem-7 was notable
for a potassium of 6, creatinine 1.7, and a blood glucose of
179. His coagulation studies were normal.
HOSPITAL COURSE: On arrival in the Emergency Department, the
patient was evaluated by the Emergency Department as well as
the General Surgery Team. A CAT scan of his abdomen revealed
pancolitis without evidence of perforation. The patient had
an x-ray of the abdomen which revealed no free air under his
diaphragm with a paucity of bowel gas, particularly distally.
An ultrasound of the scrotum revealed that his right
epididymis looked thickened while his left epididymis was
within normal limits. The patient had a right-sided
hydrocele.
The patient was started on broad spectrum antibiotic coverage
with vancomycin, Levaquin, and Flagyl. Blood cultures were
drawn and stool was sent for testing for Clostridium
difficile toxin as well as ova and parasites.
While in the Emergency Department, the patient was also
evaluated by the Urology Service to rule out the possibility
of Fournier's gangrene. In view of the patient's clinical
presentation and physical examination, he did not have the
characteristic presentation of Fournier's gangrene.
The patient was admitted to the MICU for further management.
Over the succeeding two days the patient was evaluated by the
General Surgery and Gastroenterology Services. After review
of the patient's chart, x-ray, and history, the
Gastroenterology Service was in the view that the patient
would benefit from a colonoscopy. His white cell count by
[**2167-2-8**] had increased to 30. Findings on flexible
sigmoidoscopy to 25 cm revealed that the patient had numerous
pseudomembranes and relatively normal intervening mucosa
which were all consistent with Clostridium difficile
pseudomembranous colitis. Their recommendation was that
vancomycin by mouth be added to the patient's treatment
regimen. This was done.
On [**2167-2-8**], the patient's clinical situation
appeared to be worsening with his white count elevated to 34
and with increasing abdominal distention. Following an
evaluation of the patient's status, it was decided that he
needed an emergent colectomy with ileostomy for fulminant
Clostridium difficile colitis. The risks and the benefits of
the procedure were explained to the patient and the patient
agreed to proceed.
Surgery was performed that night. The patient underwent a
total abdominal colectomy without complication. The
patient's early postoperative course was complicated by
hemodynamic instability requiring massive volume
resuscitation and Levophed supplementation as well as
multiple ventilator changes to maintain adequate oxygenation.
Over the following days while in the unit, the patient was
significantly fluid overloaded. He required paracentesis,
during which approximately 3,400 milliliters of peritoneal
fluid was drained as well as the placement of a chest tube on
[**2167-2-13**]. The patient was ultimately extubated on
[**2167-2-12**]. Tube feeds were started.
During the period until [**2167-2-17**], the patient was
slowly diuresed. He remained extubated. He was followed by
the Urology Service with no worsening in his scrotal lesions.
The patient's tube feeds by NG tube were advanced to goal.
His ostomy began to produce stool.
Of note, a small portion of the patient's incision was opened
distal to the umbilicus to allow for the patient's diagnostic
and therapeutic peritoneal lavage. This part of the incision
is currently packed with wet-to-dry dressings.
Following transfer to the floor, the patient was seen by the
Speech and Swallow service and video swallow study performed
on [**2167-2-19**]. The patient was noted to aspirate on
thin liquids but tolerated thick liquids and his diet,
therefore, was advanced.
Discharge plan was initiated. The patient's midline
abdominal incision appeared to be healing well, although as
previously noted there was a small portion distal to the
umbilicus which continued to be packed and dressed.
It is expected that the patient will be stable and be ready
for discharge on [**2167-2-20**]. Plans are to initiate a
diet of nectar-thick liquids with ground solids. Basic
aspiration precautions will be maintained. The patient will
be kept bolt upright for all meals.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg p.o. q.d.
2. Loperamide 2 mg p.o. q.i.d. p.r.n.
3. Aspirin 81 mg p.o. q.d.
4. Lisinopril 10 mg p.o. q.d.
5. Simvastatin 20 mg p.o. q.d.
6. Insulin by sliding scale.
7. Miconazole powder t.p. p.r.n.
8. Artificial tears p.r.n.
9. Albuterol nebulizer q. six p.r.n.
10. Ipratropium bromide q. six p.r.n.
11. Metoprolol 7.5 mg p.o. b.i.d.
12. Heparin 5,000 units subcutaneously b.i.d.
13. Gabapentin 300 mg p.o. q.i.d.
14. Paroxetine 10 mg p.o. q.d.
15. NPH insulin 20 units at breakfast and dinner.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **]
following discharge. The patient is also to follow-up with
his cardiologist as well as his primary care physician for
coordination of further care.
DISCHARGE DIAGNOSIS: Fulminant Clostridium difficile
colitis.
[**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2167-2-19**] 07:51
T: [**2167-2-19**] 19:57
JOB#: [**Job Number 42100**]
|
[
"008.45",
"357.2",
"250.60",
"789.5",
"511.9",
"410.92",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.15",
"45.8",
"54.91",
"48.23",
"34.04",
"96.6",
"38.91",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
6954, 6963
|
6986, 7738
|
7760, 8040
|
2808, 6932
|
1518, 1786
|
2537, 2790
|
1337, 1495
|
1803, 2023
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,319
| 113,674
|
12696
|
Discharge summary
|
report
|
Admission Date: [**2170-4-14**] Discharge Date: [**2170-4-15**]
Date of Birth: [**2091-7-29**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
post operative ST elevation myocardial infarction
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
78 year old female with history of hypertension,
hypercholesterolemia, coronary artery disease with past
angioplasty x2, congestive heart failure, paroxysmal atrial
fibrillation, s/p aortic valve replacement and mitral valve
repair for rheumatic disease, who presented initially to [**Hospital1 **] on [**4-11**] for infected artificial knee
hardware and sepsis. After undergoing resection arthroplasty
[**4-14**] the patient was transferred to the ICU, where she became
hypotensive (SBP 48) with 3mm ST elevations seen in inferoseptal
leads on ECG. CK was elevated >1600 and Troponin T was >50.
Patient was transferred to [**Hospital1 18**] for urgent cardiac
catheterization. Levophed and dopamine infusions were started
and the patient was intubated upon arrival. In catheterization,
one drug eluting stent was applied to a 80% occluding right
coronary artery lesion without residual flow defect. The patient
became hypotensive and developed ventricular tachycardia during
the procedure requiring addition of a lidocaine infusion,
maximal levophed and dopamine delivery, and balloon pump
placement. She was transferred to the CCU for further management
since her cardiac output was low at 1.8 (CI 1.2 PCWP 18) and she
continued to be hypotensive. Of note, echocardiogram on [**2170-4-3**]
showed dilated LV, severe pulm HTN 70mmHg, moderate MR, mild TR,
LVH, and normally functioning porcine AV. Ejection fraction was
normal and no wall motion abnormalities were seen.
Past Medical History:
coronary artery disease with past angioplasty x2, congestive
heart failure, paroxysmal atrial fibrillation, s/p aortic valve
replacement and mitral valve repair for rheumatic disease,
chronic renal insufficiency and acute renal failure, paroxysmal
atrial fibrillation (retroperitoneal bleed on coumadin [**10-2**]),
chronic anemia, COPD, rheumatoid arthritis, lacunar infarct,
cortical atrophy, facial droop, peptic ulcer disease [**1-31**] NSAIDS,
diverticulosis, short bowel syndrome, neuropathy, recurrent
UTI/pyelonephritis caused by Serratia and Klebsiella, s/p
colectomy [**2167**] for bowel ischemia, s/p ileostomy for recurrent
lower GI bleeding, s/p bilateral total knee replacement c/b
recurrent infection of the right knee (s/p incision and drainage
[**5-2**] for infection with klebsiella, proteus, e.coli),
degenerative disc diasease, s/p appendectomy, s/p
cholecystectomy, s/p hysterectomy, s/p tracheostomy
Social History:
home health services living with daughter [**Name (NI) **]
Family History:
father and brother died of MI
Physical Exam:
The patient was unresponsive and found to be breathless,
pulseless, and without heart tones, blood pressure, and corneal
reflexes. The patient was pronounced dead at 0515 on [**2170-4-15**].
The patient's private physician and family were notified. They
refused anatomic gifts and autopsy.
Pertinent Results:
[**2170-4-14**] 10:50PM TYPE-ART O2 FLOW-100 PO2-404* PCO2-31*
PH-7.18* TOTAL CO2-12* BASE XS--15 INTUBATED-INTUBATED
[**2170-4-14**] 10:50PM GLUCOSE-100 K+-3.5
[**2170-4-14**] 10:50PM HGB-12.2 calcHCT-37 O2 SAT-96
[**2170-4-15**] 12:56AM BLOOD WBC-26.7* RBC-3.09* Hgb-9.5* Hct-28.2*
MCV-92 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-237
[**2170-4-15**] 12:56AM BLOOD PT-18.7* PTT->150* INR(PT)-2.2
[**2170-4-15**] 12:56AM BLOOD CK(CPK)-1416*
[**2170-4-15**] 12:56AM BLOOD CK-MB-242* MB Indx-17.1* cTropnT-20.53*
[**2170-4-15**] 12:56AM BLOOD Calcium-7.0* Phos-4.1 Mg-1.7
[**2170-4-15**] 03:02AM BLOOD Type-ART pO2-180* pCO2-38 pH-7.29*
calHCO3-19* Base XS--7
[**2170-4-15**] 01:03AM BLOOD Type-ART pO2-305* pCO2-25* pH-7.08*
calHCO3-8* Base XS--21
[**2170-4-14**] 10:50PM BLOOD Type-ART O2 Flow-100 pO2-404* pCO2-31*
pH-7.18* calHCO3-12* Base XS--15 Intubat-INTUBATED
[**2170-4-15**] 01:03AM BLOOD Glucose-110* Lactate-7.9* Na-134* K-3.8
Cl-112
[**2170-4-15**] 03:02AM BLOOD Lactate-7.6*
[**2170-4-15**] 01:03AM BLOOD freeCa-1.09*
Brief Hospital Course:
78 year old female with multiple medical problems who developed
an acute myocardial infarction after orthopedic surgery at [**Hospital1 **].
.
Cardiovascular-She had known coronary disease with prior
angioplasties as well as atrial fibrillation and valvular
disease. At the OSH, the patient became hypotensive with signs
of inferoseptal myocardial infarction on ECG. At [**Hospital1 18**], the
patient received one stent that fully opened an 80% lesion in
the proximal right coronary artery. No flow limiting disease was
seen in in the LCX or LAD. However, the patient developed
hypotension and required intubation plus pressure support with
monitoring in the ICU. In spite of aggressive care on levophed,
dobutamine, vasopressin, and lidocaine; the patient became
increasingly bradycardic and expired approximately 6 hours after
admission to [**Hospital1 18**]. She was given plavix and aggrastat. Calcium
and electrolytes were repleted.
.
Pulmonary-Intubated for airway protection. Fentanyl and versed
infusions for sedation. She developed lactic acidosis (lactate
7.9) with respiratory compensation. Bicarbonate supplementation
was given without significant improvement.
.
Renal- At baseline Cr 1.4. Medications were renally dosed.
.
Musculoskeletal- The patient was status post right knee
resection arthroplasty with drain in place for recurrent right
knee prosthetic infections. Fluid analysis identified many PMNs
but no organism on gram stain. Preliminary cultures grew gram
negative rods resembling Serratia. It was sensitive to
ceftriaxone, ceftazidime, cefepime, ciprofloxacin, gentamicin,
imipenem, levoquin, bactrim, and augmentin. Resistant to
ampicillin, piperacilliin, tetracycline, and cefazolin.
Infectious disease consultation at the OSH had started
ceftriaxone 2g IV and vancomycin 650mg IV daily, which was
continued at [**Hospital1 18**]. The patient did not have fever but developed
a post MI leukocytosis.
.
GI-Iliostomy care.
.
FEN: NPO, albumin at OSH 2.9, hypocalcemia cCa 7.9/free Ca
1.08(Ca 9.6->7), hypomagnesemia. Repleted Ca and Mg.
Supplemented sodium bicarbonate for acidosis.
.
MRSA and aspiration precautions.
.
Access: Femoral line and left portacath in place. Left radial
arterial line placed at [**Hospital1 18**].
.
Code: Full
.
HCP is her daughter, [**Name (NI) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 39202**] W[**Telephone/Fax (1) 39203**],
who was present at the time of death.
Medications on Admission:
Home Meds: protonix 40', neurontin 300''', lasix 40', lomotil
2.5'''', plavix 75', verapamil 40''', ultram
OSH added calan, tylenol, vicodin, tigan, phenergan, compazine,
senna, MVI, MOM, dulcolax, [**Name2 (NI) 13426**], magnesium
All: PCN (swelling), aspirin (PUD), egg and swordfish(swelling)
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired due to hypotension and shock in spite of aggressive
care. Thought due to acute anteroseptal myocardial infarction
after orthopedic surgery at an outside hosptial.
Secondary:
coronary artery disease with past angioplasty x2, congestive
heart failure, paroxysmal atrial fibrillation, s/p aortic valve
replacement and mitral valve repair for rheumatic disease,
chronic renal insufficiency and acute renal failure, paroxysmal
atrial fibrillation (retroperitoneal bleed on coumadin [**10-2**]),
chronic anemia, COPD, rheumatoid arthritis, lacunar infarct,
cortical atrophy, facial droop, peptic ulcer disease [**1-31**] NSAIDS,
diverticulosis, short bowel syndrome, neuropathy, recurrent
UTI/pyelonephritis caused by Serratia and Klebsiella, s/p
colectomy [**2167**] for bowel ischemia, s/p ileostomy for recurrent
lower GI bleeding, s/p bilateral total knee replacement c/b
recurrent infection of the right knee (s/p incision and drainage
[**5-2**] for infection with klebsiella, proteus, e.coli),
degenerative disc diasease, s/p appendectomy, s/p
cholecystectomy, s/p hysterectomy, s/p tracheostomy
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"496",
"414.01",
"427.1",
"V43.3",
"410.61",
"E878.8",
"997.1",
"401.9",
"427.31",
"272.0",
"785.51",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"96.04",
"88.55",
"37.21",
"96.71",
"36.07",
"00.17",
"36.01",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
7132, 7141
|
4310, 6752
|
345, 357
|
8289, 8298
|
3256, 4287
|
8354, 8364
|
2896, 2927
|
7100, 7109
|
7162, 8268
|
6778, 7077
|
8322, 8331
|
2942, 3237
|
256, 307
|
385, 1859
|
1881, 2804
|
2820, 2880
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,573
| 155,752
|
15742
|
Discharge summary
|
report
|
Admission Date: [**2174-8-24**] Discharge Date: [**2174-8-28**]
Date of Birth: [**2129-4-16**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
suicidal ideation
Major Surgical or Invasive Procedure:
intubation/ventilation
History of Present Illness:
She states that she has been
grieving the death of her grandmother who died 2.5 months ago.
The patient states that her grandmother played a major role in
raising her and that she (the patient) served as the
grandmother's HCP before she died. Since then, the patient
reports weekly crying spells along with periods of time when she
feels her mood has been down, but other times when her mood
becomes expansive and euphoric. The patient says in the days
leading up to her current hospitalization, she was getting good
sleep, eating well, not having racing thoughts, or acting
recklessly. The patient does endorse episodes of rapid heart
beat, diaphoresis, associated with feeling anxious, which have
increased since her grandmother's death. She also says that she
has been thinking about "wanting to be with her grandmother." On
the day of her overdose, the patient says she was at home and
was
drinking 5 Smirnoff twisters, feeling somewhat depressed and
wishing to be with her grandmother. She then impulsively took
15mg of Klonopin and several tablets of Doxepin (she denies
taking any Lithium). The patient denies that she was thinking of
killing herself, saying instead that her act the result of her
wish to be with her grandmother. The patient adds that she did
not take all the Doxepin in her bottle because she says she knew
that if she took all of it it could be lethal. She also notes
that after taking the overdose, she blacked out and cannot
recall
what happened next, if she called for help, or how she go to
[**Hospital1 18**]. The patient says that she now regrets her actions and
that
she would never want to kill herself becasue of how this would
impact her son, [**Name (NI) 915**]. The patient says that she drinks several
times a month, but denies daily drinking. She reports continued
compliance with all her medications. She denies having auditory
or visula hallucinations at the time of this event.
Past Medical History:
PMH
Hepatitis C
Chronic Lower Back Pain
S/P multiple bilateral leg fractures s/p a MVA
Past Psychiatric History:
The patient's past history is: she reports sexual and physical
abuse by her father until she was a teen. The patient says her
father was an alcoholic and has a psychiatric disorder (but she
doesn't know what type). The patient first noted troubles with
her mood during her teen years, when she started using cocaine
and alchol. The patient says she stopped using IV cocaine in the
early 80s, but still occasional snorts cocaine (last time was
3-4
months ago). The patient has served a jail stint from [**2156**]-[**2161**]
for larceny (she says she was falsely accused), but denies
current legal troubles. The patient says she has been
hospitalized for pschiatric reasons 2 times: once 3-4 months ago
after she cut her wrist at [**Location (un) **] [**Location (un) 1459**], and one other time
at [**Hospital 45343**] Hospital. She denies any history of detoxes, seizures
or DTS, but does attend AA and NA. The patient says she started
cutting herself 2-3 years ago, and does this to relieve anxiety
and feelings of pain.
The patient gives permission to contact her current providers:
Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] (psychiatrist) [**Telephone/Fax (1) 3784**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(Therapist, same number), both work out of the [**Hospital 17065**]
[**Hospital 4189**]
Health Center.
The patient reports currently taking Lithium ?600mg daily, and
Klonopin 1mg x5 daily, and Protonix. The patient says she is
no longer prescribed Doxepin, but had some left from an old
prescription.
Social History:
The patient is currently unemployed on wellfare.
She is divorced, has 2 childre. One is in [**Doctor Last Name **] care.
The patient was in jail for 5 years for unarmed robbery. She
denies current legal troubles.
She has a long history of alcohol and cocaine use. States she
has been sober for the most part of the last year, but has had
several brief relapses.
She reports a history of sexual abuse by her step-father and
domestic violence with her former husband and current boyfriend.
Family History:
Son carries [**Name2 (NI) 45344**] of Bipolar Affective Disorder.
Physical Exam:
NAD
RRR
CTAB
Abd benign
No edema
Nonfocal neuro
Brief Hospital Course:
Pt is a bipolar woman who overdosed on klonopin, TCA's and
alcohol. Admitted to the ICU and had respiratory failure, so
was intubated. Developed fever and treated for VAP.
Successfully extubated and discharged to inpatient psychiatry.
Medications on Admission:
unclear
Discharge Medications:
Protonix 40mg daily
Valium 5mg po q6h/PRN CIWA>10 (none taken in last 24h)
Metronidazole 500mg po tid
Levofloxacin 500mg po daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
suicidal ideation
respiratory failure
ventilator associated pneumonia
Discharge Condition:
stable
Discharge Instructions:
inpatient psych
Followup Instructions:
inpatient psych
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2176-6-21**]
|
[
"070.70",
"478.6",
"980.9",
"276.2",
"305.60",
"507.0",
"E950.9",
"303.91",
"969.4",
"E950.3",
"309.81",
"969.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5123, 5193
|
4673, 4911
|
300, 324
|
5306, 5314
|
5378, 5550
|
4518, 4585
|
4969, 5100
|
5214, 5285
|
4937, 4946
|
5338, 5355
|
4600, 4650
|
243, 262
|
352, 2276
|
2298, 3992
|
4008, 4502
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,806
| 102,045
|
7309
|
Discharge summary
|
report
|
Admission Date: [**2170-10-4**] Discharge Date: [**2170-10-10**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 84 y/o female recently dx with AML on supportive
treatment only, on coumadin for atrial fibrillation and h/o TIA,
who presented to the ED with c/o maroon-colored stools x 6 days
and fatigue with SOB x several days. Pt noted blood also mixed
in with stool, but denies any increase in frequency of stool. No
abd pain, n/v/hematemesis or other changes in bowel habits.
.
In the ED, labs were significant for a Hct of 15.8, WBC of 45.8,
and INR of 7.7. Maroon stool, guiac positive in rectum but NG
lavage negative. Pt was hemodynamically stable throughout. She
was given 1 U PRBC, 2 U FFP, and 5 mg SC vit K. GI was consulted
in the ED and feels this may be a LGIB, but also could be a
UGIB. Conversation with PCP and family lead to decision of
tagged RBC scan to attempt localization of site in an effort to
avoid invasive procedures, including EGD/colonoscopy given
comorbid conditions. Tagged RBC scan demonstrated brisk bleeding
from the cecum.
.
Currently, pt fatigued, but otherwise denies other sx including
LH/dizziness, h/a, vision changes, URI sx,
SOB/palpitations/chest pain, abd pain, n/v,
weakness/numbness/loss of sensation, dysuria. No further BM's
since yesterday.
Past Medical History:
1. Atrial fibrillation with a history of TIA 10 years ago on
chronic anticoagulation with Coumadin.
2. Status post left hip replacement.
3. Polymyalgia rheumatica, previously treated with steroids,
with persistent proximal leg weakness.
5. Osteoporosis.
6. Status post total abdominal hysterectomy with bilateral
salpingo-oophorectomy.
7. Mild-to-moderate Alzheimer dementia.
Social History:
The patient lives with her husband in [**Name (NI) 2312**], MA. She has
never smoked and drinks one glass of wine per day. She is quite
physically active and walks approximately one quarter of a mile
daily and lifts weights twice a week. Family involved in care,
pt is DNR/DNI.
Family History:
NC
Physical Exam:
VS: T 98.8, BP 132/53, HR 90's, RR 29, SaO2 98%/RA
General: Pleasant elderly female in NAD, AO x 2 (place, year)
HEENT: NC/AT, PERRL, EOMI. No scleral icterus. +conjuntival
pallor. MM slightly dry, OP clear
Neck: supple, no JVD
Chest: CTA-B, no w/r/r
CV: RRR, s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS. Guiac positive in ED.
Ext: pt has chronic LE pain, refuses exam of LE
Neuro: AO x 2, non-focal
Pertinent Results:
[**2170-10-4**] 03:30PM GLUCOSE-114* UREA N-29* CREAT-0.8 SODIUM-141
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
[**2170-10-4**] 03:30PM CK(CPK)-26
[**2170-10-4**] 03:30PM cTropnT-<0.01
[**2170-10-4**] 03:30PM WBC-45.8*# RBC-1.60*# HGB-5.4*# HCT-15.8*#
MCV-99* MCH-34.0* MCHC-34.5 RDW-20.5*
[**2170-10-4**] 03:30PM PT-61.9* PTT-34.4 INR(PT)-7.7*
.
Brief Hospital Course:
84 y/o female with AML, Alzheimer's dementia, Afib and h/o TIA's
on coumadin, p/w acute drop in Hct and maroon-colored stools.
.
# GIB - tagged RBC scan demonstrates brisk bleeding from cecum,
likely in setting of coagulopathy. Pt was hemodynamically stable
throughout the course of her stay. Spoke with IR, who
recommended medical management with PRBCs and FFP for now as pt
stable and procedure invasive given pt's co-morbid conditions.
Family and pt agreed with conservative management. Hct was 30
and stable upon discharge.
.
# AML - currently on supportive treatment for AML. Pt may be in
acute blast crisis given leukocytosis of 45 K, with prior counts
at 13 K. She is managed for goal of comfort at this time by
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She will be discharged on 7
days of PO levofloxacin for neutropenia.
.
# A fib - rate-controlled on digoxin.
.
# Dementia - Mild to moderate Alzheimer's, at baseline.
Continued Aricept and Namenda.
.
#Dispo - patient is being discharged to nursing home unit at her
[**Hospital3 **] complex with goals of care directed at comfort
only.
Medications on Admission:
1. Aricept 5 mg [**Hospital1 **]
2. Coumadin 4 mg M/W/F, 5 mg S/[**Doctor First Name **]/Tues
3. Detrol 1 mg [**Hospital1 **]
4. Digoxin 250 mcg qd
5. Fosamax 70 mg qweek
6. Namenda 10 mg [**Hospital1 **]
7. MVI qd
8. Ca/Vit D qd
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
Disp:*30 Tablet(s)* Refills:*1*
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO QDAY () for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 8463**] [**Last Name (NamePattern1) **] House/Hospice
Discharge Diagnosis:
Primary
Lower GI bleed
.
Secondary
AML
Discharge Condition:
Stable
Discharge Instructions:
Please contact your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], if you have any pain or
concerns upon discharge.
Followup Instructions:
Please contact your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], if you have any pain or
concerns.
At this time, you do not have any scheduled follow up.
|
[
"578.1",
"790.01",
"331.0",
"V12.59",
"E934.2",
"790.92",
"413.9",
"780.6",
"427.31",
"288.00",
"205.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4797, 4907
|
2998, 4137
|
227, 234
|
4990, 4999
|
2606, 2975
|
5181, 5358
|
2164, 2168
|
4418, 4774
|
4928, 4969
|
4163, 4395
|
5023, 5158
|
2183, 2587
|
179, 189
|
262, 1453
|
1475, 1853
|
1869, 2148
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,949
| 107,767
|
46414
|
Discharge summary
|
report
|
Admission Date: [**2200-6-28**] Discharge Date: [**2200-7-6**]
Date of Birth: [**2144-5-29**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 530**]
Chief Complaint:
syncopal event
Major Surgical or Invasive Procedure:
hemodialysis via left arm A-V graft
History of Present Illness:
This is a 56 yo F with HTN, h/o atypical thrombotic
microangiopathy with secondary focal sclerosis off [**First Name3 (LF) **] for
the last year, hepatitis B and C, hypothyroidism here with
syncopal event and acute renal failure, now with hypotension of
unclear etiology. Patient is a poor historian, but states that
she fell on tuesday because she tripped over a wire and hit her
bottom and her head. [**First Name3 (LF) 2974**], she had another fall with unclear
circumstances because she can't remember what happened per ED.
She denied cp, sob, palpatations, etc prior to this event. She
complains of left leg pain. She has erythema and serous blisters
over L hip with hematoma. Labs done in the ED reveal a
creatinine of 8.8 which is up from a baseline of [**3-9**].5 with some
values [**6-10**]. Her BUN is also elevated at 65. Pt reports some
decreased po intake for unclear reasons and decreased urination.
She denies using nsaids, vomiting, diarrhea. She is on
diuretics. Pt denies metallic taste in her mouth, pruritis,
frothy urine, nausea or vomiting. She is not confused.
In the ED, initial vs were T 98.6, HR 92, BP 126/71, R 18, O2
sat 99% RA. Head CT negative. CXR negative. EKG non-ischemic and
unchanged from prior. Labs notable for creatinine 8.8 with bun
65.
On the floor, patient slept comfortably and ate well. She denies
LOC.
Past Medical History:
Acute on Chronic Renal Failure, [**2198-8-4**], thought [**3-8**]
Vancomycin
Atypical Thrombotic Microangiopathy since [**2187**]
CKD, baseline Cr 2.0-recent ARF with increaced Cr to 5.0
Steroid induced osteoporosis
Obesity
HTN
Hep B and C (past IV drug use)
h/o heart murmur
L radius fracture, ([**7-11**])
Cataract surgery, L eye 2 mo ago, R eye 2 yrs ago
Migraines
Social History:
Divorced, lives alone. Has two sisters and aunt for social
support. Unemployed since [**2187**]. Has one daugher in [**Hospital1 1474**].
Smoking-40yr smoking hx-currently <1ppd, but formerly more.
Prior IVDA, last used heroin 10 years ago. Currently on
Methadone maintenance.
Family History:
Father died from unkown malignancy at age 78
Mother had uterine ca-died at age 81
Siblings in good health
No FH of kidney or blood dz, no hx of heart disease
Physical Exam:
Vitals T 98 P 89 BP 130/62 R 18 O2 sat 96% RA
General comfortable, nad
HEENT NCAT, anicteric, no injections, PERRLA, OP clear, MM very
dry
Neck supple, no LAD
Heart RRR, s1s2, loud 3/6 sem RUSB, no friction rub
Lungs CTA
Abd +bs, soft, nt, nd
Ext no cce, chronic venous stasis changes bl
Neuro A/C x 3, neuro exam nonfocal, no asterixis
Pertinent Results:
[**2200-6-28**] 08:30PM WBC-8.7 RBC-4.39 HGB-11.8* HCT-37.9 MCV-86
MCH-26.8* MCHC-31.1 RDW-19.6*
[**2200-6-28**] 08:30PM NEUTS-66.1 LYMPHS-22.4 MONOS-4.8 EOS-6.1*
BASOS-0.6
[**2200-6-28**] 08:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2200-6-28**] 08:30PM PLT COUNT-291
[**2200-6-28**] 08:30PM PT-37.9* PTT-40.3* INR(PT)-4.1*
[**2200-6-28**] 08:30PM GLUCOSE-86 UREA N-65* CREAT-8.8*# SODIUM-134
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-15* ANION GAP-20
[**2200-6-28**] 08:30PM CALCIUM-7.3* PHOSPHATE-7.7*# MAGNESIUM-2.0
[**2200-6-28**] 08:30PM C3-139 C4-42*
[**2200-6-28**] 08:30PM CK(CPK)-4028*
[**2200-7-2**] 07:25AM BLOOD Hapto-193
[**2200-7-5**] 09:00AM BLOOD WBC-7.5 RBC-4.05* Hgb-10.6* Hct-35.6*
MCV-88 MCH-26.2* MCHC-29.7* RDW-18.9* Plt Ct-339
[**2200-7-5**] 07:12AM BLOOD PT-24.0* PTT-35.6* INR(PT)-2.3*
[**2200-7-5**] 09:00AM BLOOD Glucose-79 UreaN-35* Creat-7.5* Na-139
K-4.2 Cl-108 HCO3-19* AnGap-16
[**2200-7-5**] 09:00AM BLOOD Albumin-3.2* Calcium-7.9* Phos-6.1*
AP CHEST RADIOGRAPH: No consolidation, pneumothorax or pleural
effusion. Cardiomegaly and central pulmonary vascular congestion
are present, although without evidence of overt edema. The
mediastinum and hila are within normal limits. Tandem vascular
stents are seen within the right subclavian and brachiocephalic
veins and proximal SVC.
AP PELVIS AND FIVE VIEWS OF THE LEFT FEMUR.
There is no fracture or dislocation. Calcific density is seen
adjacent to the greater tuberosity on a single projection which
likely represents calcific gluteal tendinopathy. Vascular
calcifications are present. Limited views of the knee show
tricompartmental osteoarthritis
EKG:
Sinus rhythm. Delayed precordial R wave transition. Compared to
the previous tracing of [**2200-6-28**] no diagnostic interim change.
The rate has slowed.
Transthoracic Echocardiogram:
The left atrium is mildly dilated. The left atrial volume is
markedly increased (>32ml/m2). The right atrium is moderately
dilated. The estimated right atrial pressure is 10-15mmHg. 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%). The estimated cardiac index is
normal (>=2.5L/min/m2). Transmitral Doppler and tissue velocity
imaging are consistent with Grade II (moderate) LV diastolic
dysfunction. There is no left ventricular outflow obstruction at
rest or with Valsalva. The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2198-9-27**],
the left ventricle is more hypertrophied and the estimated
pulmonary artery systolic pressure has increased. No vegetation
is seen.
Brief Hospital Course:
A/P: A/P: Pt is a 56 yo female with pmhx thrombotic
microangiopathy, CKD, HTN here with several syncopal episodes
and acute on chronic renal failure
.
# Transient Hypotension: On arrival to floor from ED, patient's
blood pressure was low, responded to reducing dose of methadone
from 20 to 10, gentle hydration with isotonic bicarbonate, and
holding BP meds x24 hrs. Stable since on home amlodipine and
metoprolol.
# systolic murmur: Patient also has a harsh murmur, which raises
suspicion for endocarditis, but is afebrile and aside from
hypotension, does not manifest signs of infection. TTE was
normal, with no veg or hemodynamically significant LV outflow
obstruction or AS; suspect aortic sclerosis.
# Acute on chronic renal failure: UOP low initially but pt now
making 500-600cc/day. Baseline Cr 2-3.5 secondary to TTP, peaked
at 10.4 and hemodialysis re-initiated. Suspect [**3-8**]
rhabdomyolysis given elevated CPK on admission. Blood
bank/[**Month/Day (2) **] team did not find any indications for [**Month/Day (2) **],
which was considered given patient's history of atypical
microangiopathy. Continued niferex, epogen, calcitriol at outpt
doses.
Pt will need HD on a Tues/Thurs/Sat schedule with ongoing
re-evaluation of need for hemodialysis.
# Fall, ? Syncope: Pt denies LOC and insists fall was
mechanical. CT head without acute bleed. She did have 14 beats
of VT on telemetry in ICU, asymptomatic (see below), no known
structural heart disease, but with murmur. Also could be renal
failure causing increased circulating levels of methadone.
- ECHO to evaluate for structural heart disease in setting of
murmur was normal
- TSH slightly high, T4 slightly low; increased levothyroxine to
75 mcg daily
# HTN- restarting norvasc and metoprolol
# hypothyroidism- increased levothyroxine to 75 mcg daily for
high tsh/low t4
# H/O IVDA- continue methadone, but at lower dose. No additional
narcotics. Hold for sedation.
# FEN/GI - cardiac, renal diet, IVF as above, replete lytes prn
# PPx - protonix, restarting coumadin at half dose today given
INR of 3.0, bowel regimen
# Code - full
# Dispo: to acute rehab for HD; after 1-2 weeks, will be better
able to determine need for ongoing hemodialysis vs improvement
in renal function.
Medications on Admission:
ALLOPURINOL 100 mg--2 tablet(s) by mouth every day
BUMEX 2 mg--1 tablet(s) by mouth once a day
CALCITRIOL 0.25 mcg--one capsule(s) by mouth every other day
EPOGEN 10,000 unit/mL--1 ml subcutaneously twice a week
FOSAMAX 70 mg--1 tablet(s) by mouth once a week
LEVOXYL 50 mcg--1 tablet(s) by mouth once a day
METOPROLOL TARTRATE 25 mg--1 tablet(s) by mouth twice a day
Methadone 5 mg/5 mL--20 mg by mouth daily
NIFEREX 60 mg--1 capsule(s) by mouth once a day
NORVASC 5 mg--one tablet(s) by mouth once a day
OXAZEPAM 30 mg--two capsule(s) by mouth at bedtime
PHENERGAN 25 mg--one tablet(s) by mouth every 4-6hrs as needed
PLAVIX 75 mg--one tablet(s) by mouth one a day
PRILOSEC OTC 20 mg--1 tablet(s) by mouth daily
Syringe (Disposable) --3 ml syringe, 25 g, [**6-12**] inch needle
twice a week to use for procrit injection
WARFARIN 2 mg----- tablet(s) by mouth daily take up to 3 tablets
daily, as directed by coumadin clinic [**Telephone/Fax (1) 10844**]
Discharge Medications:
1. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) units
Injection QMOWEFR (Monday -Wednesday-[**Telephone/Fax (1) 2974**]): during dialsysis.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Methadone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
note: outpatient methadone maintenance dose was 20, decreased
[**3-8**] somnolence.
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Oxazepam 15 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime) as needed.
13. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Outpatient [**Month/Day (2) **] Work
Check INR regularly and restart warfarin when appropriate for
INR target [**3-9**]
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
acute renal failure due to rhabdomyolysis, acute tubular
necrosis (possibly)
history of atypical thrombotic microangiopathy c/b secondary
focal sclerosis; has not required plasmapheresis since [**2198**]
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
You were admitted to the hospital and then the intensive care
unit because you had some times in which you fell, and then your
blood pressure was low. You may have been sedated because of a
combination of methadone and possibly other medicines; it's
important that you stay on a steady dose of methadone to make
sure you don't become overly sedated. You had damage to your
muscles which had the effect of damaging your kidneys; you also
may have had other reasons that your kidneys were damaged. For
now you will need dialysis and close follow-up with the kidney
doctors [**Name5 (PTitle) 1028**] your [**Name5 (PTitle) 4006**] function improves. You had a urinary
tract infection as well while you were in the hospital, for
which you received antibiotics.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2200-7-16**] 10:30
Provider: [**First Name11 (Name Pattern1) 2482**] [**Last Name (NamePattern4) 10466**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2200-7-25**] 9:00
PCP:
|
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
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|
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|
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|
11415, 11422
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
2111, 2393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,658
| 106,978
|
32808
|
Discharge summary
|
report
|
Admission Date: [**2143-3-1**] Discharge Date: [**2143-3-8**]
Date of Birth: [**2095-1-14**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Tylenol overdose/encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48 y/o male w/ a hx of HCV cirrhosis, who was transferred to
[**Hospital1 18**] from ICU at [**Hospital3 2737**] for altered mental status,
noted to have a tylenol level of 51 at [**Hospital3 2737**], no
tylenol level checked at [**Last Name (LF) **], [**First Name3 (LF) **] OSH records, he received IV
mucomyst there 150mg/kg over 50min , then 50mg per/kg over 4
hours, then 100mg/kg over 16 hours.
.
Pt was originally brought to [**Hospital3 2737**], because of
domestic dispute with wife, where he made homicidal threats
against her. Patient has reportedly had past psych admits to
[**Last Name (LF) 2025**], [**First Name3 (LF) **] attain records.
.
Pt transferred to [**Hospital1 18**] late on [**3-1**] out of concern for tylenol
toxicity, concern for impending liver failure, possible SBP
reported abd tenderness and fever to 101 at osh, and MS changes
(encephalopathy vs. frank psychosis). Of note pt is no longer
active on transplant list, because of both suicidal and
homicidal ideation.
.
MICU course: During micu stay patient received, ceftriaxone 1mg
x one dose, 8400mg of mucomyst. Team felt that he was unlikely
to have SBP, and was not treated as such. No paracentesis. Pt
was continued on Nadolol, rifaximin, lactulose, prn haldol and
risperidol. Patient extremely aggitated at times, still
endorsing suicidal and homicidal ideation "against his wife".
Other times calm, but w/ loose associations, admits to olfactory
hallucinations, and reported to at times respond to internal
stimuli.
.
.
(FOR MORE DETAILS SEE MICU ADMIT NOTE BELOW)
Reason for transfer: Tylenol overdose/encephalopathy
.
HPI: 48 year old male with HCV cirrhosis presenting altered
mental status and tylenol overdose. The patient has known
cirrohosis and has been considered for transplant in the past,
but is not currently listed due to a psychiatric
hospitalization. He has been seen recently in the liver clinic
for fluid accumulation and had his diuretics and diet adjusted.
.
The patient arrives to [**Hospital1 18**] and is not responding to history
questions. History is obtained from the OSH records. The patient
was taken to the ED after a domestic altercation with homicidal
ideation, with a specific desire to injure his wife. [**Name (NI) **] asked to
be restrained because he felt like he wanted to kill someone,
but did not know why. He denied hallucinations. During the ED
work up, he was found to have a Tylenol level of 51. He
reporedly taking acetaminophen nightly for insomnia for an
unspecified period of time and an unspecified amount. Some
reports indicate he was taking Tylenol PM to aide with sleep. He
was treated with activated charcoal and mucomyst (started 62.5
cc/hr started at 9 am on [**2143-3-1**], stopped, likely at transfer at
8 pm), and his Tylenol level improved. Ammonia level at
admission was 5, and coagulation profile was at baseline, so it
was not suspected that the patient was in fulminant failure. He
did report persistent ascites, though compliance with his
diuretics is unclear. [**Name2 (NI) **] was scheduled for ultrasound guided
paracentensis, but was started on ceftriaxone empirically.
Psychiatry saw the patient and felt he was depressed and started
him on Celexa and recommended decreasing his Risperdal. He was
transferred for further care at [**Hospital1 18**].
Past Medical History:
Past Medical History:
-Cirrhosis: from HCV infection. Complicated by variceal bleed
([**2138**]) w/p EGD and banding last in [**11-24**], ascites on diuretics,
hyponatremia, and hepatic encephalopathy. Had been listed for
transplant at [**Hospital1 2025**], but removed after psychiatric hospitalization
for SI/HI. Last seen in liver clinic by Dr. [**Last Name (STitle) 497**] [**2143-2-23**]. Last
colonoscopy in [**11-24**]. Reported baseline coagulopathy, with INR
between [**1-20**].
-Hypertension
-Pancytopenia
-Depression, Anxiety
-GERD
Social History:
Social history: married with 1 daughter, smokes 1.5 ppd. + h/o
etoh (sober X 3 years) and drugs (intranasal cocaine), but
apparently quit in [**2138**]. On disability
Family History:
Denies liver disease in family.
Physical Exam:
PE:
vitals: T98.3, BP 108/51, HR 50s-60s, RR 18, 98% on RA
General: tangential, responsive to name, intermittently answers
questions, responds to internal stimuli,
HEENT: no icterus, EOMI
Car: RRR
Resp: CTAB-ant/lat, would not cooperate with further exam
Abd: + BS, distended, soft,
Ext: no LE edema 2+ DP, No asterixis
NEURO: CN 2-12 intact, normal strength, nl sensory exam, equal
reflexes through out.
Skin: jaundice
Pertinent Results:
ADMISSION LABS:
[**2143-3-2**] 03:26AM BLOOD WBC-3.4* RBC-3.14* Hgb-10.2* Hct-31.2*
MCV-100* MCH-32.5* MCHC-32.7 RDW-18.2* Plt Ct-15*#
[**2143-3-2**] 03:26AM BLOOD Neuts-64.9 Lymphs-25.6 Monos-8.1 Eos-1.0
Baso-0.4
[**2143-3-2**] 03:26AM BLOOD PT-19.3* PTT-43.2* INR(PT)-1.8*
[**2143-3-2**] 03:26AM BLOOD Glucose-85 UreaN-11 Creat-1.0 Na-132*
K-3.5 Cl-98 HCO3-27 AnGap-11
[**2143-3-2**] 03:26AM BLOOD ALT-40 AST-117* LD(LDH)-304* AlkPhos-149*
TotBili-5.0*
[**2143-3-2**] 03:26AM BLOOD Albumin-2.5* Calcium-8.6 Phos-3.6 Mg-1.7
[**2143-3-4**] 03:09AM BLOOD VitB12-1889* Folate-15.7
[**2143-3-2**] 03:26AM BLOOD TSH-0.40
[**2143-3-2**] 03:26AM BLOOD Acetmnp-NEG
[**2143-3-3**] 04:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
[**2143-3-8**] 05:50AM BLOOD WBC-2.7* RBC-3.04* Hgb-9.9* Hct-30.1*
MCV-99* MCH-32.7* MCHC-33.0 RDW-19.1* Plt Ct-20*
[**2143-3-8**] 05:50AM BLOOD Neuts-71.4* Lymphs-21.7 Monos-5.3 Eos-1.2
Baso-0.3
[**2143-3-8**] 05:50AM BLOOD Plt Ct-20*
[**2143-3-8**] 05:50AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-131*
K-3.8 Cl-97 HCO3-28 AnGap-10
[**2143-3-8**] 05:50AM BLOOD ALT-35 AST-101* LD(LDH)-272* AlkPhos-145*
TotBili-3.9*
[**2143-3-8**] 05:50AM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.2 Mg-2.1
[**2143-3-4**] 03:09AM BLOOD VitB12-1889* Folate-15.7
[**2143-3-6**] 03:53PM BLOOD Ammonia-22
[**2143-3-6**] 04:00PM BLOOD TSH-1.1
[**2143-3-3**] 04:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
EEG [**3-7**]
OBJECT: PSYCHOSIS AND DELIRIUM. ? SEIZURES.
.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
.
BACKGROUND: Included a well-formed 9 Hz alpha frequency in
posterior
areas bilaterally during wakefulness.
HYPERVENTILATION: Produced no activation of the record.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient appeared to remain awake throughout the
recording.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Normal EEG in the waking state. There were no focal
abnormalities or epileptiform features.
CT HEAD W/O CONTRAST [**2143-3-3**] 3:26 PM
.
NON-CONTRAST CT HEAD: There is no evidence of infarction,
hemorrhage, shift of normally midline structures, or edema. The
imaged paranasal sinuses and mastoid air cells are unremarkable.
The osseous structures are unremarkable.
.
IMPRESSION: Normal study.
ECHO [**2-28**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
RADIOLOGY Final Report
.
CTA ABD W&W/O C & RECONS [**2143-2-28**] 12:37 PM
.
There are stigmata of chronic liver disease with nodular,
atrophied liver and moderate amount of perihepatic and
perisplenic ascites. Spleen is enlarged. There are varices seen
within the splenic hilum, perigastric and paraesophageal region.
Recanalized paraumbilical vein is noted. There is a single
hepatic hypodensity, which is too small to characterize, but
likely a benign cyst, without change on delayed phase imaging.
Decompressed gallbladder is noted. There is no biliary
dilatation. Moderate amount of mesenteric edema is evident,
likely on the basis of increased portal pressures. Portal vein
remains patent. Hence, the hepatic arterial anatomy is
conventional and patent.
.
No dilated loops of bowel.
.
PELVIS: There is a fat-containing umbilical hernia.
.
Kidneys enhance and excrete contrast symmetrically. There is a
left renal cyst. The bowel loops are decompressed. Nondistended
bladder is seen in the deep pelvis. There is a small amount of
pelvic ascites. Atherosclerotic calcifications.
No focal osseous lesions.
IMPRESSION: Stigmata of chronic liver disease including
cirrhotic shrunken liver, ascites, recanalized umbilical vein,
splenomegaly and varices. Conventional hepatic arterial anatomy.
Patent portal vein. No suspicious focal hepatic lesions.
Brief Hospital Course:
IMPRESSION:
48 y/o male w/ HCV cirrhosis, ESLD, w/ hx of varices and
encephalopathy who presents from OSH, w/ tylenol ingestion, and
likely psychosis. Continued homicidal ideation toward wife and
son and suicidal ideation. EEG normal [**3-7**].
.
Patient would likely be discharged to rehab if not for his
endorsement of voices telling him to kill his wife with a knife.
Patient endorses these voices at different times of the day at
other times he denies them.
.
# Homicidal ideation w/ ? Psychosis vs. Delirium: Pt appears to
be responding to internal stimuli. MMSE very high, Still
endorses voice that tell him to kill his wife and son w/ a
knife. He denies that he would actually do this. He has no
active plans of Suicide or murder. These symptoms come and go
during the day. Psychiatry feels that the waxing and [**Doctor Last Name 688**] does
not fit entirely with a primary psychiatric disorder. However
patient is atypical for hepatic encephalopathy. Cont to monitor
for improvement with long term plans of trial of inpatient psych
evaluation. Patient needs to have all psychiatric comorbitidies
controlled for him to be considered for liver transplant.
.
Also of note, wife and son were notified of these homicidal
ideations on [**3-7**]. Patient was continued on the following psych
medications, Citalopram 10mg daily, Risperidone 3mg po bid,
0.5mg risperidone PRN, Haldol 5-10mg IV q4PRN. Pt was calm for
the 48 hours prior to transfer to [**Hospital1 **] 4.
.
# Encephalopathy: Patient does not appear encephalopathic,
ammonia 22, no asterixis, MMSE very high today, perfect on
serial sevens, and memory. Patient not currently
encephalopathic, but will become so if he does not continue his
current dose of rifaximin/lactulose
.
#Transient Hypotension: Pt was noted to have, transient sbp of
86 after receiving spironolactone and nadolol with in 30min of
one another. On recheck 15min later patients blood pressure was
96/50 baseline. We suggest that patient receive 40 of lasix in
the morning, spironolactone at noon and nadolol at night.
.
# Cirrhosis: INR is stable at patient's baseline per records,
continue to trend. Patient with ascites, and unclear if
compliant with diuretics. Continue aldactone and Lasix.
Continued on nadolol dose reduced from 40mg to 20mg for history
of esophageal varices. INR at baseline. Platelet count 22. Felt
that patient did not have SBP clinically. MELD score near
baseline at MELD 19. Patient follows with Dr. [**Last Name (STitle) 497**] from the
liver service at [**Hospital1 18**].
.
#Tylenol ingestion: history consistent with daily tylenol
ingestion on a cirrhotic liver, though exact dose/intent/timing
is unclear. [**Name2 (NI) **] received NAC infusion with 5 additional
hours for 16 hours at 17.5 mg//kg/hr dosing as well as NAC
infusion at [**Hospital3 2737**] prior to transfer
.
# Thrombocytopenia: Nadir of 15 this hospital stay continue to
monitor, at transfer platelets were 20. Platelet transfusions
are likely only accumulate in spleen.
.
#Anemia: HCT 28-30 pt is near baseline. Probably related to
anemia of chronic disease given liver disease.
.
#Leukopenia: Stable, likely related to liver disease.
.
#. Chronic back pain: continue oxycontin. Reduced dose from 40mg
[**Hospital1 **] to 20mg [**Hospital1 **], during hospital stay.
.
#. GERD: continue protonix
.
#. FEN: low salt diet. Hyponatremia of 130s at baseline.
.
#. PPx: Avoided heparin sq, as patient all ready coagulopathic.
.
#. Access: PIV
.
#. Code: Full
.
# Dispo: Depending on psych issues.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] [**MD Number(1) 8953**]
1.
Medications on Admission:
Medications (per Dr.[**Name (NI) 948**] Notes)
Lasix 20 mg [**Hospital1 **]
Lactulose 45 cc tid
Reglan 5 mg po tid
Nadolol 20 mg daily
Omeprazole 20 mg daily
oxycontin 60 mg [**Hospital1 **]
rifaximin 400 mg tid
risperdal 1 mg [**Hospital1 **]
aldactone 100 mg daily
Thiamine 100 mg daily
Vitamin K 100 mcg daily
.
Medications at transfer:
Lactulose 30 ml q8h
Lasix 40 mg daily
Aldactone 100 mg daily
Nadolol 40 mg daily
Protonix 40 mg [**Hospital1 **]
Oxycontin 60 mg [**Hospital1 **]
Xanax 0.25 mg daily
Ceftriaxone 1 gm IV daily
Thiamine 100 mg daily
Risperdal 0.5 mg [**Hospital1 **]
NAC
Folate 1 mg po daily
Celexa 10 mg daily
Ativan
Family history:
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID
(4 times a day).
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO PRN (as
needed) as needed for agitation.
6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime)).
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
9. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Nadolol 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO qam.
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY AT
NOON ().
13. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary Diagnosis.
1. End Stage Liver Disease(Cirrhosis)
2. Psychosis NOS
3. Enchephalopathy
4. Delirium
5. Tylenol toxicity
6. Homicidal Ideation
.
Secondary Diagnosis
1. Hepatitis C
2. Thrombocytopenia
3. GERD
4. Leukopenia
5. Hx of varices
6. Chronic lower back pain
Discharge Condition:
stable, normotensive SBP 100
Discharge Instructions:
Mr. [**Known lastname **] you were transferred to [**Hospital1 18**] from [**Hospital3 2737**] out
of concern for your mental status changes and your high tylenol
levels. While you were at [**Hospital3 2737**] at while you were at
[**Hospital1 18**] you received mucomyst which helped protect your liver from
tylenol toxicity.
.
There was also intial concern that you might have an infection
in your abdomen, but this was felt not to be the case by the
team. You were still very confused when you were in the ICU. You
needed medications to help calm you down.
.
You were given medications to help control any confusion caused
from your liver disease. You had a test called an RPR which rule
out any syphyllis causing your confusion. You had an EEG which
did not show any seizure activity. You did not have any
infection in your urine.
.
You continued to hear voices and be confused during your
hospitalizations. You repeatedly stated that you heard a voice
telling you to kill your wife, your son and yourself. As a
result we are transitioning you to a psychiatry facitilty to
determine if you have a primary psychiatric problem on top of
your other liver issues, and to further assess if you are a
danger to yourself or others.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 22166**] once you are discharged from the hospital.
.
Please contact the [**Hospital1 18**] liver center on discharge from the
hospital.
.
Please keep the following appointments.
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2143-3-12**]
2:00
|
[
"965.4",
"789.59",
"276.1",
"298.9",
"287.5",
"070.44",
"E850.4",
"571.5",
"288.50"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14727, 14772
|
9256, 12888
|
296, 303
|
15086, 15117
|
4898, 4898
|
16394, 16858
|
13571, 13571
|
13594, 14704
|
14793, 15065
|
12914, 13553
|
15141, 16371
|
5671, 7089
|
4458, 4879
|
225, 258
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331, 3643
|
7098, 9233
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4915, 5654
|
3687, 4210
|
4242, 4394
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,936
| 131,505
|
9455
|
Discharge summary
|
report
|
Admission Date: [**2107-2-10**] Discharge Date: [**2107-2-16**]
Date of Birth: [**2023-5-16**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Demerol / Ambien / Bacitracin /
Hydrocortisone / Escitalopram / Neomycin / Polymyxin B
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
positive troponin leak, shortness of breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
83 y/o M w/ ischemic cardiomyopathy with EF 20-25%, extensive
CAD history including CABG x1, which was redone, s/p 4 prior
stents who was initially admitted to an outside hosital with CHF
exacerbation. He was discharged to rehab on [**2106-2-8**]. On arrival
to the OSH, patient reported that he had 2 days of increasing
shortness of breath but denied chest discomfort, nausea,
diaphoresis. He presented to the OSH ED on [**2-10**] where on
arrival vital signs were T 101.2, HR 122, RR 25-26, BP135/85, O2
92% RA. He was treated with IV lasix 80mg x2, nitro paste, and
respirations seemed to improve, but patient transitioned to
BiPap for additional support. Echo at the OSH revealed no
significant change from prior, but CEs were elevated. Initial
preference on part of family was for conservative management,
but patient's respiratory status worsened and his labs suggested
an acute event. After consultation and discussion with
cardiology patient was transfered to [**Hospital1 18**] for further
management.
Prior to transfer, vs were T97, 71, 24, 99/66, On BiPap 97%,
earlier on NRB. Patient was restless and diaphoretic, chest pain
free.
Review of systems could not be obtained on arrival to [**Hospital1 18**].
On arrival, VS were Afebrile, HR 122, BP 135/70, RR 37-40, O2
sat 93-95% on BiPap. Patient was in marked respiratory distress.
He was given 80mg IV lasix, nitro gtt, morphine IV. After 30
minutes, he showed no improvement. ABG showed progression of CO2
retention with worsening acidemia in face of 35-40 breaths per
minute. Patient was intubated at that time after discussion with
patient and family given rising CO2 and lack of response to
medical therapy. R-IJ and a-line placed on arrival in addition
to two new peripheral IVs.
Past Medical History:
1. CAD (see below)
2. s/p radical prostatectomy [**2090**]
3. Carotid artery disease with right external carotid stenosis
of 90% and severe left external carotid stenosis
4. Hypertension
5. Gout
6. Osteoarthritis
7. Diabetes mellitus
8. Hyperlipidemia
CARDIAC HISTORY:
CABG in [**2087**]: SVG-RPDA, SVG-OM, LIMA-D1.
Re-do CABG in [**2096**] (via left thoracotomy): SVG from Descending
Thoracic Aorta to OM, SVG from Descending Thoracic Aorta to
R-PDA.
Last cardiac cath on [**2104-10-2**], anatomy as follows:
1. Selective angiography demonstrated three (3) vessel native
coronary artery disease. The right coronary artery was not
engaged. The left main coronary artery demonstrated an 80% hazy
lesion that extended into the left circumflex artery. The left
anterior descending artery was occluded proximally.
2. The LIMA-LAD graft was not engaged. The SVG-OM graft
demonstrated a widely patent stent with normal flow throughout.
The SVG-PDA was known to be occluded and was not engaged.
3. LV ventriculography was deferred.
4. Limited hemodynamics demonstrated central hypertension
(190/70 mm Hg).
5. Successful PTCA and stenting of the left main coronary artery
extending into the proximal left circumflex artery with three
overlapping Cypher (2.5x13mm; 3x13mm; 3x18mm) drug eluting
stents which were postdilated with a 3mm and 3.5mm balloon.
Final angiography demonstrated no residual stenosis, no
angiographical apparent dissection and TIMI III flow.
Social History:
30-pack-year tobacco history. No ETOH abuse.
Family History:
Father died age 59 from heart disease; mother died age 66 with
childhood rheumatic fever and fatal MI.
Physical Exam:
Admission Exam:
Gen: elderly male in respiratory distress
Chest: bilateral diffuse crackles, rapid rhythm
Abd: soft, nontender, nondistended
Ext: 1+ edema bilateral lower extremities
Pertinent Results:
[**2107-2-11**] 12:03AM BLOOD WBC-21.7*# RBC-3.66* Hgb-11.5* Hct-36.0*
MCV-98 MCH-31.5 MCHC-32.0 RDW-14.9 Plt Ct-294
[**2107-2-11**] 02:40PM BLOOD WBC-9.8 RBC-3.08* Hgb-9.4* Hct-29.9*
MCV-97 MCH-30.7 MCHC-31.6 RDW-14.8 Plt Ct-231
[**2107-2-15**] 04:56AM BLOOD WBC-15.0*# RBC-3.10*# Hgb-10.1*#
Hct-30.2* MCV-97 MCH-32.5* MCHC-33.4 RDW-15.2 Plt Ct-227
[**2107-2-11**] 12:03AM BLOOD Neuts-80.4* Lymphs-15.0* Monos-4.2
Eos-0.1 Baso-0.2
[**2107-2-11**] 12:03AM BLOOD PT-14.8* PTT-79.0* INR(PT)-1.3*
[**2107-2-14**] 05:14AM BLOOD PT-13.4 PTT-28.9 INR(PT)-1.1
[**2107-2-11**] 12:03AM BLOOD Glucose-243* UreaN-52* Creat-2.4*# Na-141
K-5.0 Cl-103 HCO3-23 AnGap-20
[**2107-2-12**] 05:00AM BLOOD Glucose-152* UreaN-61* Creat-2.1* Na-143
K-4.2 Cl-107 HCO3-28 AnGap-12
[**2107-2-14**] 05:14AM BLOOD Glucose-169* UreaN-65* Creat-1.6* Na-149*
K-4.0 Cl-112* HCO3-26 AnGap-15
[**2107-2-15**] 04:56AM BLOOD Glucose-208* UreaN-73* Creat-1.7* Na-150*
K-4.1 Cl-112* HCO3-24 AnGap-18
[**2107-2-11**] 12:03AM BLOOD ALT-52* AST-230* LD(LDH)-732*
CK(CPK)-2107* AlkPhos-95 TotBili-0.5
[**2107-2-11**] 05:36AM BLOOD CK(CPK)-1547*
[**2107-2-12**] 05:00AM BLOOD CK(CPK)-766*
[**2107-2-15**] 04:56AM BLOOD ALT-41* AST-49* LD(LDH)-367* CK(CPK)-163
AlkPhos-74 TotBili-0.5
[**2107-2-14**] 05:14AM BLOOD Lipase-44 GGT-13
[**2107-2-11**] 12:03AM BLOOD CK-MB-71* MB Indx-3.4 cTropnT-3.41*
proBNP-[**Numeric Identifier 32234**]*
[**2107-2-11**] 05:36AM BLOOD CK-MB-45* MB Indx-2.9 cTropnT-2.78*
[**2107-2-15**] 04:56AM BLOOD CK-MB-5 cTropnT-2.42*
[**2107-2-11**] 12:03AM BLOOD HBsAb-NEGATIVE
[**2107-2-15**] 09:49AM BLOOD Vanco-15.1
[**2107-2-11**] 12:03AM BLOOD HCV Ab-NEGATIVE
[**2107-2-10**] 11:52PM BLOOD Type-ART Rates-/30 Tidal V-600 PEEP-5
FiO2-100 pO2-88 pCO2-48* pH-7.32* calTCO2-26 Base XS--1
AADO2-577 REQ O2-95 Intubat-NOT INTUBA
[**2107-2-15**] 06:29AM BLOOD Type-ART Temp-36.9 FiO2-50 pO2-149*
pCO2-33* pH-7.45 calTCO2-24 Base XS-0 Intubat-NOT INTUBA
[**2107-2-11**] 01:24AM BLOOD Glucose-201* Lactate-2.4*
[**2107-2-11**] 05:46AM BLOOD Glucose-225* Lactate-1.6
[**2107-2-14**] 04:57PM BLOOD Glucose-149* K-3.6
[**2107-2-15**] 06:29AM BLOOD Lactate-2.7*
[**2107-2-14**] 01:04PM BLOOD freeCa-1.10*
Radiology Report CHEST (PORTABLE AP) Study Date of [**2107-2-10**]
11:28 PM
FINDINGS: In comparison with study of [**2104-9-16**], there is a
substantial
increase in the cardiac silhouette with severe pulmonary edema
and bilateral
pleural effusions, slightly more prominent on the right.
Pacemaker device
with two channels remains in place. Opacification in the
retrocardiac region
is consistent with atelectatic change.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2107-2-10**]
11:28 PM
FINDINGS: In comparison with study of [**2104-9-16**], there is a
substantial
increase in the cardiac silhouette with severe pulmonary edema
and bilateral
pleural effusions, slightly more prominent on the right.
Pacemaker device
with two channels remains in place. Opacification in the
retrocardiac region
is consistent with atelectatic change.
CHEST (PORTABLE AP) Study Date of [**2107-2-15**] 7:54 AM
FINDINGS: As compared to the previous examination, there is no
relevant
change. Minimally improved ventilation of the right lung,
potentially
reflecting a minimal decrease of the pre-existing pleural
effusion.
Otherwise, the extent of the effusions, the extent of the
retrocardiac
atelectasis and the signs of mild-to-moderate overhydration are
unchanged.
Unchanged size of the cardiac silhouette. No evidence of newly
appeared focal
parenchymal opacities suggesting pneumonia.
Portable TTE (Complete) Done [**2107-2-14**] at 3:03:02 PM FINAL
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy with normal cavity size and severe
global hypokinesis. The basal inferolateral wall contracts best
(LVEF= 15-20 %). No left ventricular thrombus is seen. Right
ventricular chamber size is normal with free wall hypokinesis.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-25**]+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
severely global left ventricular hypokinesis c/w diffuse process
(toxin, metabolic, multivessel CAD, etc. ). Severe aortic valve
stenosis. Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2104-9-16**],
there has been a marked deterioration in global left ventricular
systolic function the calculated aortic valve area is smaller.
Mild-moderate mitral regurgitation is also new.
Cardiology Report Cardiac Cath Study Date of [**2107-2-11**]
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease, with no change in
status as
compared to [**7-/2106**] catheterization. Patent LIMA and SVG-OM.
2. Moderate aortic stenosis.
3. Severe diastolic ventricular dysfunction.
Brief Hospital Course:
Mr. [**Known lastname 32235**] was an 83 year old male with aortic stenosis,
ischemic cardiomyopathy with EF 25%, extensive 3 vessel CAD
history including 2 seperate CABG surgeries first in [**2087**] with
multiple revisions and stents to his native vessels, s/p
multiple stents, who was transferred from an outside hospital
with dyspnea and troponin leak.
# Acute on Chronic Systolic and Diastolic Congestive Heart
Failure
Patient with end-stage heart failure, presenting with another
heart failure exacerbation; his family noted that he had
multiple recent exacerbations, increasing in frequency. He was
diuresed at the outside hospital but was in respiratory distress
again on presentation to [**Hospital1 18**]. After trial of BiPap, he was
intubated. A PA catheter showed elevated wedge pressures and
pulmonary hypertension. He was diuresed gently in the setting
of aortic stenosis and extubated successfully to BiPap. The
family changed Code Status to DNR and Do Not Re-Intubate prior
to extubation. Post extubation, the patient had increasing
difficulties with breathing, so he was started on a lasix drip.
The family soon made the decision to keep the patient on Comfort
Measures only. The patient was started on a morphine drip and
passed away comfortably in the presence of his family.
# Type II MI:
Patient had elevated cardiac enzymes at the outside hospital,
likely demand ischemia in the setting of diffuse coronary artery
disease and congestive heart failure exacerbation. Patient
underwent Cardiac Catheterization which showed three vessel
coronary artery disease, similar to previously, patent LIMA and
SVG-OM. Echocardiogram apparently unchanged from previous, no
new wall motion abnormalities, not likely any ischemic event
precipitating the heart failure exacerbation. Patient was
continued on aspirin, plavix, statin. He was initially on
heparin drip for treatment of possible NSTEMI, until it was felt
that he was not having an NSTEMI.
# Aortic Stenosis:
Patient had estimated valve area of 0.6cm2 which was increased
to 1.2cm2 with dobutamine administration during Echo. His volume
status was carefully managed in the setting of aortic stenosis
and fluid overload prior to moving to comfort measures.
# Acute Renal Failure:
Patient had acute renal failure, likely secondary to poor
forward flow with low cardiac output in setting of aortic
stenosis and heart failure exacerbation. He
# Hypertension:
Patient's blood pressures were controlled on nitroglycerin drip
on transfer to [**Hospital1 18**]. He was easily weaned off of the nitro
drip overnight, and blood pressures remained stable without
restarting his home medications.
# Diabetes:
Metformin was held during this hospitalization. Blood sugars
were controlled on Humalog insulin sliding scale.
# Gout:
Patient was given renally dosed allopurinol.
# Code Status: Patient was Full Code on presentation, but HCP
[**Name (NI) 1158**] changed Code Status to DNR/DNI, then Comfort Measures Only.
Patient passed away comfortably in presence of his family.
Medications on Admission:
Medications at home:
allopurinol 300 qod
amlodipine 10mg daily
aspirin 325 EC daily
Benicar 40mg daily
calcium 600mg daily
diazepam 5mg daily
furosemide 80mg daily
hydralazine 25mg daily
isosorbide mononitrate ER 120mg daily
Lipitor 80mg daily
metformin 500mg daily
Toprol XL 150 [**Hospital1 **]
Plavix 75mg daily
Potassium 20 meq daily
Protonix 40mg daily
Ranexa 100mg [**Hospital1 **]
MVI
Colchicine prn
nitro prn
.
Medications on transfer:
Aspirin 325
Norvasc 5mg daily
Lipitor 80mg daily
Plavix 75mg daily
colace 100mg [**Hospital1 **]
pepcid 20mg [**Hospital1 **]
lasix 100mg IV q24
Hydralazine 25mg PO BID
Novolog sliding scale
albuterol neb prn
atrovent neb prn
toprol XL 50mg daily
heparin gtt
morphine prn
ceftriaxone IV q24
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute on Chronic Congestive Heart Failure
Demand Ischemia
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
None
|
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[
[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,555
| 128,111
|
5568
|
Discharge summary
|
report
|
Admission Date: [**2158-8-29**] Discharge Date: [**2158-9-5**]
Date of Birth: [**2106-10-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Portacath removal.
PICC line placement.
History of Present Illness:
51 year old male with Crohn's disease and short gut syndrome on
chronic TPN with h/o multiple line infections, presented to the
ED with dyspnea. He was in his USOH until the middle of last
week when he developed URI symptoms, including nasal congestion
and dry cough. On the night of [**8-28**], he developed dyspnea and
worsening cough. He had no fever or chills at home. He denies
sputum production, nausea, vomiting, increased ostomy output,
abdominal pain, headache, rash, urinary symptoms. He states he
has had normal po fluid and food intake. He denies change in
urine output or color. He has noticed to blood or black output
from his ostomy. ROS positive for some back pain and myalgias.
In the ED, vital signs on presentation were T 102.9, HR 90, BP
123/53, RR 24, O2sat 95% RA. On exam, he was noted to be
tachypneic but in NAD, bilateral wheezes, and warm extremities.
His Tmax in the ED was 103.3. His BP subsequently dropped to
83/54, and increased to 100/56 after 4L NS. He was also placed
on 4L O2, O2sat 94%. He was subsequently placed on NRB. Blood
cultures were sent and CXR and ECG were performed. He received a
total of 5L NS, vancomycin 1g IV, levofloxacin 500mg IV,
ibuprofen 800mg po, Tylenol 1g, and morphine 1mg IV. Vascular
Surgery was contact[**Name (NI) **] for removal of his R portacath, which was
placed by Dr. [**Last Name (STitle) 519**] in [**5-2**].
Mr. [**Known lastname **] was initially admitted to the MICU for further
management. On arrival to the MICU, he denied shortness of
breath, chest pain, chills, back pain, nausea or vomiting. He
stated that his symptoms did not feel similar to past line
infections, as they usually manifest with fever and rigors
immediately after infusion into the line.
Past Medical History:
1. Crohn's disease- s/p multiple bowel resections, on 6-MP in
the past
2. Short Gut Syndrome on chronic TPN
3. Multiple central line infections with MSSA, E.Coli,
enterobacter, Stenotrophomonas, Acinetobacter, Klebsiella
4. H/o septic pulmonary emboli ([**10-1**], no endocarditis on TTE)
5. RML Bronchiectasis
6. Recent RUL nodular opacities of unclear etiology (followed by
Dr. [**Last Name (STitle) 575**]
7. Mild restrictive lung disease (PFTs [**1-30**])
PSH:
1. Proctocolectomy with ileostomy
2. Parathyroidectomy
3. Cholecystectomy
Social History:
Works in finance department at [**Hospital6 33**]. Wife is a
nurse manager. Lives with wife and 2 kids, 18 and 15yo. + h/o
tobacco-1ppd x 15-20y, quit 20y ago. Denies EtOH and IVDU.
Family History:
No fhx of CAD, CVA, or CA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T 99.5, BP 107/50, HR 82, RR 20, O2sat 98% on 70%FM
General- face mask in place, NAD, A&Ox3
HEENT- sclerae anicteric, PERRL, dry MM, OP clear
Neck- no JVD
Pulm- decreased breath sounds and dullness to percussion at
bilateral bases, + rales 1/3 up b/l, + rhonchi and egophony at R
mid lung field
CV- RRR, [**1-2**] HSM heard best at LLSB
Abd- + ostomy bag in L mid abd, + BS, multiple healed surgical
scars incl. midline and RUQ, nondistended, nontender, no
hepatomegaly
Extrem- warm and well-perfused, no LE edema or cyanosis
Neuro- A&Ox3
PHYSICAL EXAM ON TRANSFER TO FLOOR:
Vitals- Tm 101; Tc afeb, BP 97/53, HR 72, RR 22-24, O2sat 98%
General - cachectic, sitting comfortably, NAD, A&Ox3
HEENT - sclerae anicteric, PERRL, MMM, OP clear
Neck - no JVD
Pulm - decreased breath sounds and dullness to percussion at
bilateral bases, scattered rhonchi L base
CV - RRR, nl s1/s2, no m/r/g
Abd - + ostomy bag in L mid abd, + scant BS, multiple healed
surgical scars incl. midline and RUQ, nondistended, nontender,
no hepatomegaly
Extrem - 2+ distal pulses, warm and well-perfused, no LE edema
or cyanosis
Neuro - A&Ox3, non-focal
Pertinent Results:
[**2158-8-29**] 06:20AM PT-12.7 PTT-31.0 INR(PT)-1.1
[**2158-8-29**] 06:20AM PLT COUNT-87*
[**2158-8-29**] 06:20AM MICROCYT-1+
[**2158-8-29**] 06:20AM NEUTS-91.3* LYMPHS-6.7* MONOS-1.7* EOS-0.1
BASOS-0.2
[**2158-8-29**] 06:20AM WBC-6.8 RBC-3.92* HGB-11.6* HCT-31.9* MCV-81*
MCH-29.6 MCHC-36.4* RDW-13.7
[**2158-8-29**] 06:20AM VIT B12-822 FOLATE-13.7
[**2158-8-29**] 06:20AM CALCIUM-8.0* PHOSPHATE-3.0 MAGNESIUM-1.6
[**2158-8-29**] 06:20AM GLUCOSE-108* UREA N-20 CREAT-1.1 SODIUM-131*
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-24 ANION GAP-12
[**2158-8-29**] 06:32AM LACTATE-1.0
[**2158-8-29**] 06:40AM URINE AMORPH-FEW
[**2158-8-29**] 06:40AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2158-8-29**] 06:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-8-29**] 06:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2158-8-29**] 06:40AM URINE GR HOLD-HOLD
[**2158-8-29**] 06:40AM URINE HOURS-RANDOM
[**2158-8-29**] 02:52PM HCT-31.5*
[**2158-8-29**] 02:52PM ALBUMIN-2.5* CALCIUM-7.1* PHOSPHATE-2.9
MAGNESIUM-1.7
[**2158-8-29**] 02:52PM GLUCOSE-92 UREA N-13 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11
.
IMAGING:
ECG: NSR @ 95bpm, normal axis and intervals, some Twave
flattening in III/aVF, no significant change from prior study in
[**3-2**].
.
CXR:
1) Right middle lobe and left lower lung zone opacities,
suspicious for pneumonia.
2) Right middle lobe bronchiectasis.
3) Bilateral pleural effusions.
.
[**2158-8-30**] CT L-spine
No evidence of epidural abscess or vertebral osteomyelitis.
Congenital dysmorphic appearance of upper cervical vertebrae and
occipital bone.
.
[**2158-9-2**] CT CHEST W/ CONTRAST: 1. Diffuse and patchy
ground-glass opacities seen throughout all segments of the
lungs, more severely involving the upper lobes than the lower
lobes, with some nodular components. These findings are
consistent with multifocal pneumonia. No cavitating nodules are
seen. 2. No evidence of pulmonary embolism. 3. Splenomegaly,
which appears more pronounced than on the prior examination. 4.
PICC extends into the neck, although it curls back inferiorly,
with the tip facing a caudal direction. On subsequent
fluoroscopic spot images, the catheter is seen to be
appropriately repositioned by the CVIR service.
.
[**2159-9-5**] TEE: No evidence of endocarditis.
Brief Hospital Course:
In the MICU, Mr. [**Known lastname **] became increasing dyspnic and hypoxic
secondary to volume overload from aggressive hydration. However,
he improved with diuresis. He was treated with vancomycin for
presumed Portacath infection and possible bacteremia. His
Portacath was removed by Vascular surgery on [**2158-8-29**]. Blood and
PAC tip cultures eventually grew coagulase negative staph in 4
of 4 bottles and he was continued on vancomycin. His respiratory
status improved such that he maintained his oxygen saturation on
2 liters nasal canula. His back pain was concerning initially
for osteomyelitis, but it resolved, thus no additional imaging
studies were pursued.
His chest radiograph and symptoms were concerning for multilobar
pneumonia. Given his history of septic pulmonary emboli, without
documented endocarditis, a TTE and TEE were both performed but
negative. Vancomycin and levofloxacin were used for antibiotic
coverage. He did not require oxygen at discharge.
Mr. [**Known lastname **] was noted to have a microcytic anemia and was without
any evidence of bleeding. Stool guiac was negative. B12 and
folate levels were normal. Iron was found to be low, so
nutritional supplementation was initiated. He was also noted to
be chronically thrombocytopenic and found to have a postive
heparin antibody test. He reported that he had been using
heparin products to flush his PAC at home. All heparin products
were discontinued on this admission.
For his short gut syndrome, ostomy output was monitored and
reported to be at baseline. A PICC line was placed and TPN was
initiated when he became afebrile.
Medications on Admission:
Coumadin 1mg qod
Immodium
DTO
Discharge Medications:
1. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
2. Opium Tincture 10 mg/mL Tincture Sig: Fifteen (15) Drop PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every eight (8) hours for 7 days.
Disp:*21 grams* Refills:*0*
4. TPN
Resume home regimen at home cycling schedule.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
please check vancomycin trough, CBC, chem 7 on [**2158-9-7**], fax
results to Dr. [**First Name (STitle) 572**] (office number [**Telephone/Fax (1) 1983**]).
7. PICC line care
per protocol, please do not use any heparin products, do not use
any heparin flushes. This pt has active heparin induced
thrombocytopenia.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 22402**] Homecare
Discharge Diagnosis:
Sepsis
Discharge Condition:
Stable. Afebrile, no nausea/vomiting.
Discharge Instructions:
Please return to the ED or call your doctor if you experience
any of the following: fever > 101.5, intractable
nausea/vomiting, severe pain, shortness of breath or any other
concerning symptoms.
.
Please take all medications as prescribed.
.
Please follow-up with all appointments as scheduled.
.
Note that you have active heparin induced thrombocytopenia;
please do not ever use heparin for any reason, including to
flush your ports or IVs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Date/Time:[**2158-9-18**] 2:00.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2158-10-12**] 8:40
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2158-10-12**] 9:00
Follow-up with Dr. [**Last Name (STitle) 519**] in [**11-28**] weeks to consider permanent IV
access placement. Call [**Telephone/Fax (1) 6554**] to make an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
|
[
"518.81",
"486",
"579.3",
"038.11",
"V12.51",
"276.8",
"287.5",
"995.92",
"458.9",
"280.9",
"996.62",
"276.52",
"555.9",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9135, 9195
|
6593, 8214
|
334, 376
|
9246, 9286
|
4144, 6570
|
9776, 10477
|
2923, 2951
|
8294, 9112
|
9216, 9225
|
8240, 8271
|
9310, 9753
|
2991, 4125
|
275, 296
|
404, 2145
|
2167, 2708
|
2724, 2907
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,042
| 115,282
|
35525
|
Discharge summary
|
report
|
Admission Date: [**2104-4-2**] Discharge Date: [**2104-4-11**]
Date of Birth: [**2068-11-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
jaundice, BRBPR
Major Surgical or Invasive Procedure:
Endoscopy x 2 with variceal banding
History of Present Illness:
35F with long history of etOH abuse (last drink 10 PTA), s/p
gastric bypass, 4 days BRBPR, and new jaundice. She also reports
abdominal bloating but denies pain, F/C/NS or melena prior to
admission. She intially presented to [**Hospital **] hospital where she
was found to have a HCT 21 and TBili 17. NG lavage was negative.
She recieved 2U pRBCs, 6U FFP, and levofloxacin for a preseumed
UTI. She was transfered to [**Hospital1 18**] for further management.
.
In the ED her VS were T99.0 P101 BP99/53 R18 95% on RA. She was
comfortable but jaundiced on exam with a distended, nontender
abdomen. Exam was notable for appreciable fluid in abdomen and
mild to moderate ascites by bedside US. Her intitial HCT here
was 23 so she received an additional 2U pRBCs. She was initially
admitted to the MICU for management of her acute alcoholic
hepatitis and presumed GIB.
.
In the MICU she started on IV PPI, octreotide, and ciprofloxacin
for UTI. She was seen by the hepatology team who did an EGD
which revealed 3 cords of grade I and 1 [**Last Name (un) 4782**] II varices and a
colonscopy which revealed melena and medium grade 2 external
hemorrhoids. An ECHO was performed for low voltage EKG and
peripheral edema to rule out pericardial effusion and dilated
cardiomyopathy, which was negative. A CT abdomen was performed
which showed an 18cm distended gall bladder for which surgery
was consulted.
.
Past Medical History:
Alcohol abuse
Gastric bypass in [**2100**]
Chronic neck pain
Suicide attempt with flexeril overdose in [**2103**]
Social History:
[**2-1**] PPD for the past year. Drank about 3L wine per day for past
year. Vodka often. Last drink 10 days PTA. Denies other
substance abuse.
Family History:
CAD in father and grandfather, breast cancer in grandmother
Physical Exam:
GEN: NAD, jaundiced, talkative
VS: T:98.6 BP:98/64 P:98 RR:18 O2Sat 97% RA
HEENT: Clear OP, MMM, icteric sclera, no JVD, no LAD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA on R, bronchial breath sounds at L base
ABD: Collateral veins present. BS+. Distended with shifting
dullness. Tender epigastrium, no rebound, liver palpable 4cm
below the costal margin in the mid-axillary line and spleen
palpable 1-2cm belowe the costal margin in the anterior axillary
line
EXT: 1+ edema
SKIN: jaudniced, dry
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-1**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission labs:
[**2104-4-2**] 09:30PM BLOOD WBC-14.5* RBC-2.32* Hgb-8.3* Hct-23.0*
MCV-100* MCH-35.8* MCHC-35.9* RDW-22.2* Plt Ct-248
[**2104-4-2**] 09:30PM BLOOD PT-21.3* PTT-41.8* INR(PT)-2.0*
[**2104-4-2**] 09:30PM BLOOD Glucose-79 UreaN-21* Creat-0.6 Na-125*
K-3.5 Cl-87* HCO3-25 AnGap-17
[**2104-4-2**] 09:30PM BLOOD ALT-67* AST-240* AlkPhos-159*
TotBili-14.4* DirBili-9.6* IndBili-4.8
[**2104-4-2**] 09:30PM BLOOD Albumin-2.3* Calcium-7.4* Phos-3.1 Mg-2.4
.
Discharge labs:
[**2104-4-11**] 10:35AM BLOOD WBC-16.9* RBC-2.88* Hgb-9.9* Hct-28.7*
MCV-100* MCH-34.3* MCHC-34.4 RDW-19.8* Plt Ct-266
[**2104-4-11**] 10:35AM BLOOD PT-19.9* PTT-49.0* INR(PT)-1.9*
[**2104-4-11**] 10:35AM BLOOD Glucose-76 UreaN-14 Creat-1.0 Na-133
K-3.2* Cl-105 HCO3-19* AnGap-12
[**2104-4-11**] 10:35AM BLOOD ALT-43* AST-123* LD(LDH)-151 AlkPhos-113
TotBili-13.7*
[**2104-4-11**] 10:35AM BLOOD Calcium-7.6* Phos-2.3* Mg-2.1
.
Serologies:
[**2104-4-2**] 09:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2104-4-2**] 09:30PM BLOOD HCV Ab-NEGATIVE
[**2104-4-3**] 04:03AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2104-4-3**] 04:03AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2104-4-3**] 04:03AM BLOOD AFP-4.1
[**2104-4-3**] 04:03AM BLOOD IgG-1397 IgA-723* IgM-154
.
Urine studies:
[**2104-4-2**] 10:00PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-LG Urobiln-12* pH-6.5 Leuks-NEG
[**2104-4-2**] 10:00PM URINE RBC-0-2 WBC-[**7-9**]* Bacteri-FEW Yeast-NONE
Epi-[**4-3**] TransE-[**4-3**] RenalEp-0-2
.
Tox screen:
[**2104-4-2**] 10:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
DUPLEX DOP ABD/PEL LIMITED Study Date of [**2104-4-2**] 9:35 PM
FINDINGS: The liver is diffusely echogenic consistent with fatty
infiltration. While no focal hepatic lesion is identified,
evaluation is limited by difficult son[**Name (NI) 493**] penetration.
There is no intrahepatic biliary ductal dilatation. While portal
venous flow is intermittently identified in the left portal and
extrahepatic main portal vein, reliable color flow is not
acheived in the intrahepatic or right portal venous system. The
common bile duct measures 5 mm. The gallbladder is significantly
distended with sludge, but there are no gallstones,
pericholecystic fluid or wall thickening, and the onographic
[**Doctor Last Name **] sign is negative. Small ascites is present. The spleen
appears normal though the pancreas is not well seen. There is no
right hydronephrosis. IMPRESSION: 1. Diffusely echogenic liver
may be consistent with fatty infiltration. However, other forms
of liver disease and more advanced liver disease (i.e.,
significant hepatic fibrosis/cirrhosis) cannot be excluded. 2.
Reliable intra-hepatic portal venous color flow is difficult to
achieve and thrombosis cannot be completely excluded. CT is
recommended for further evaluation. 3. Distended gallbladder
with sludge, but no evidence for cholecystitis. 4. Small
ascites.
.
CT ABDOMEN W/CONTRAST Study Date of [**2104-4-3**] 4:10 PM CT ABDOMEN:
Small effusions are associated with relaxation atelectasis.
There is no consolidation or nodule in the lung bases. Heart
size is normal. There is no pericardial effusion. Diffusely
enlarged fatty liver has patchy enhancement in all phases. The
SMV, splenic and portal veins are patent. There are gastric and
splenic varices. The celiac and superior mesenteric arteries are
patent. Replaced right hepatic artery arises from the SMA. The
pancreas and adrenals are unremarkable. The gallbladder is
markedly distended, measuring 18 (CC) x 6 (AP) x 7 (ML) cm. The
spleen remains mildly enlarged, measuring 12.7 cm. Post-gastric
bypass changes are noted. The imaged intra- abdominal loops of
large and small bowel are unremarkable without evidence of
pneumatosis, free air or obstruction. There is no mesenteric or
retroperitoneal lymphadenopathy. Moderate ascites tracks along
the paracolic gutters into the pelvis. Diffuse subcutaneous
stranding represents anasarca. Bone windows demonstrate no
evidence of lesion that is suspicious for metastasis or
infection. IMPRESSION: 1. No evidence of SMV, splenic or portal
thrombosis. 2. Diffuse anasarca and moderate ascites. 3.
Enlarged fatty liver with heterogeneous perfusion reflects
cirrhosis. 4. Markedly enlarged gallbladder without evidence of
gallstones or cholecystitis. 5. Moderate bilateral pleural
effusions. 6. Gastric and splenic varices.
.
MRCP (MR ABD W&W/OC) Study Date of [**2104-4-5**] 6:11 PM FINDINGS:
The gallbladder is significantly distended and there are some
folds seen within. There is small amount of sludge within the
gallbladder and the wall is not appreciably thickened. The
cystic duct does not appear dilated. The common bile duct is
normal in caliber without evidence of stones. There is no
intrahepatic biliary ductal dilatation. No pancreatic ductal
dilatation. The liver is enlarged measuring 26 cm in length. The
liver is significantly fatty showing signal dropout on the
out-of-phase images. There is a small amount of ascites. There
are also minimal bilateral pleural effusions and subcutaneous
edema and fluid is also seen in the left pararenal space. There
is atelectasis of the bilateral lung bases. Sutures are seen in
the stomach, probably from prior gastric bypass surgery. No
focal masses are seen in the liver on the post-contrast images.
There is mild narrowing of the proximal celiac artery with acute
angulation which could be due to stenosis (this can be a normal
variant in assymptomatic patients). There are two right renal
arteries incidentally noted. There is no bulky adenopathy.
Multiplanar 2D and 3D reformations delineated the dynamic series
with multiple perspectives. IMPRESSION: 1. Hepatomegaly with
fatty liver. 2. Distended gallbladder with minimal sludge. No
evidence of biliary ductal dilatation.
.
CHEST (PA & LAT) Study Date of [**2104-4-4**] 2:26 PM Since yesterday,
lung volumes are still low. Small-to-moderate pleural effusion
is new. Small left pleural effusion increased. Bibasilar
opacities increased, likely atelectasis. Left retrocardiac
opacity increased, could be atelectasis or pneumonia. There is
no other overall change.
Brief Hospital Course:
35F with history of gastric bypass and etOH abuse who was
transfered to [**Hospital1 18**] with acute etOH hepatitis, dilated gall
bladder, evidence of cirrhosis, and GIB with an initial HCT of
21. Endoscopy showed varices and portal gastropathy but no
active bleeding. Tbili rose to >20 and then declined. INR peaked
at 2.0 and began to fall prior to discharge. HCT stabilized. Pt
was incidentally noted to have an enlarged gall bladder but MRCP
was WNL. Her physical exam and CXR were concerining for
pneumonia, which was treated with antibiotics against CAP and
aspiration PNA. She was discharged to her parents' home with
close follow up.
.
#. Alcoholic hepatitis: New onset jaundice for 2 weeks prior to
admission. Max AST/ALT of 250/67 with max Tbili 21.3. Had GI
bleed from portal gastropathy. Evidence of collaterals on CT
concerning for chronic underlying cirrhosis. Viral hepatitis
negative as were serologies for autoimmune hepatitis. This was
likely all related to alcohol abuse. Management of varices as
below. Started on spironlactone 50mg PO daily for LE edema as
well as midodrine for orthostatic hypotension.
.
#. Possible PNA: Pt with rising WBC and bilat bronchial breath
sounds of exam as well as worsening infiltrates on CXR
concerning for PNA. Unclear if this is a communitiy acquired PNA
or [**3-3**] aspiration from endoscopy. Treated with levofloxacin 750
mg PO Q24H for community aquired PNA from [**2104-4-6**] to [**2104-4-11**] for
a 5 day course
and clindamycin 300 mg PO Q6H hepatically dosed for anaerobic
coverage for possible aspiration from [**2104-4-6**] to [**2104-4-11**] for a 5
day course.
.
#. GI bleed: likey secondary to portal hypertensive gastropathy
seen on EGD. She recieved initial 4U pRBCS and additional units
PRN later in the admission. She was treated with an IV PPI and
octreotide. Her HCT has stabilized around 27. Had variceal
banding at repeat EGD on [**2104-4-7**]. Discontinued Nadolol as s/p
banding and had been hypotensive. Switch to Pantoprazole 40 mg
PO daily and discharged on this medication at this dose.
.
#. Hypotension / orthostatic hypotension: Recurrent this
admisison likely due to hypovolemia and hypoalbuminemia. DCed
nadolol. Started midodrine 10mg PO TID with good effect.
Discharged on this medication.
.
#. Dilated gall bladder: mildly painful, 18cm on CT scan, does
not appear infected, but like obstructed, no gall stones but +
sludging. [**Month (only) 116**] be a normal variant from gastric bypass. MRCP read
showed hepatomegaly with fatty liver, a distended gallbladder
with minimal sludge, and no evidence of biliary ductal
dilatation.
.
#. UTI: Levaquin given at OSH. Repeat UCx no growth (final).
Repeat UA with 6-10 WBC. Initially on Ciprofloxacin HCl 500 mg
PO Q12H, but then treated with levofloxacin for PNA as above
which would cover common UTI pathogens.
.
#. Alcohol abuse: Reportedly last drink was >2 weeks ago. SW
Consulted with patient. Will continue to have close follow up on
this issue.
Medications on Admission:
Multivitamin
Vitamin A
Vitamin D
Vitamin K
Iron
Discharge Medications:
1. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day: for swollen legs.
Disp:*30 Tablet(s)* Refills:*5*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): for
bleeding in your stomach.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*5*
3. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): for low blood pressure.
Disp:*90 Tablet(s)* Refills:*5*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary: Alcoholic hepatitis, GI bleeding
.
Secondary: Cirrhosis, alcohol abuse
Discharge Condition:
Stable vital signs, tolerating POs
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].
.
You were admitted for alcoholic hepatitis. This is injury to
your liver from drinking alcohol. You had bleeding in your GI
tract from this. We did an endoscopy and placed bands on varices
or dilated veins in your esophagus. You improved and are being
discharged home with physical therapy and close follow up.
.
Please take your medications as ordered.
.
Do no drink alcohol. Alcoholic hepatitis is a potentially fatal
condition.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the emergency room if you
experience confusion, bleeding, excessive bruising, fevers,
chest pain, shortness of breath, decrease in urine output,
passing out, or other concerning symptoms.
Followup Instructions:
[**2104-4-21**] 11:10a [**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] (LIVER CENTER)
LM [**Hospital Unit Name **], [**Location (un) **]
LIVER CENTER (SB)
[**Telephone/Fax (1) 2422**]
Completed by:[**2104-4-14**]
|
[
"572.3",
"456.21",
"571.1",
"537.89",
"571.2",
"276.2",
"486",
"569.3",
"305.1",
"280.0",
"276.1",
"599.0",
"303.91",
"507.0",
"455.3",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"42.33",
"99.07",
"48.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12697, 12746
|
9134, 12123
|
287, 325
|
12870, 12907
|
2936, 2936
|
13718, 13948
|
2067, 2128
|
12222, 12674
|
12767, 12849
|
12149, 12199
|
12931, 13695
|
3417, 9111
|
2143, 2917
|
232, 249
|
353, 1753
|
2952, 3401
|
1775, 1891
|
1907, 2051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,418
| 189,967
|
14726+14727
|
Discharge summary
|
report+report
|
Admission Date: [**2103-8-14**] Discharge Date: [**2103-8-16**]
Date of Birth: [**2026-8-11**] Sex: F
Service: ICU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 17832**] is a 77-year-old
female with diabetes, chronic renal insufficiency, and
history of urosepsis in the past who presents to the
Intensive Care Unit post procedure.
The patient had a protracted hospital course back in [**2103-5-26**] when she presented with hypotension and respiratory
distress. The patient was subsequently found to have Proteus
bacteria in her urine and blood. She had an obstruction of
her left renal pelvis and required ureteral stent placement.
At that time, a post stent placement pus was extruded after
the stent was placed.
Subsequently, the patient was titrated off chemical pressors
and extubated and had several bouts of bacteremia including
vancomycin-resistant enterococcus and methicillin-resistant
Staphylococcus aureus associated with central lines. She was
ultimately discharged to rehabilitation and was in recovery.
In the interim she had been in rehabilitation, relatively
doing fine and was scheduled for ureterostomy stent change
and stone ablation on the day of [**8-14**].
Per Urology team, intraoperatively, the patient's urine after
ureteral change was "dirty" and stone was ablated.
Apparently, after extubation in the Postanesthesia Care Unit,
the patient subsequently became more lethargic and was
intubated. She subsequently dropped her blood pressures down
to 60 systolic, and a central line was placed, and she was
started on chemical pressors. She was subsequently
transferred to the Medical Intensive Care Unit for further
care.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Chronic renal insufficiency.
3. Status post bilateral mastectomy for comfort.
4. Cerebrovascular accident with residual left hemiparesis
in [**2099**].
5. Hypercholesterolemia.
6. Status post total abdominal hysterectomy.
7. Status post appendectomy.
8. History of [**Last Name (un) 43324**] urosepsis.
9. Status post myocardial infarction during last Intensive
Care Unit course in [**2103-5-26**].
10. Hypertension.
ALLERGIES: Allergies include questionable allergy to
PENICILLIN, SULFA, ERYTHROMYCIN, and CIPROFLOXACIN which
cause either gastrointestinal upset or rash.
MEDICATIONS ON ADMISSION: Medications at home included
Docusate 100 mg p.o. b.i.d., captopril 6.25 mg p.o. t.i.d.,
Lopressor 50 mg p.o. t.i.d., Lipitor 20 mg p.o. q.d., NPH 20
units q.a.m. and 15 units q.p.m., Protonix 40 mg p.o. q.d.,
multivitamin, Lasix 40 mg p.o. q.d., iron sulfate 325 mg p.o.
q.d., Zoloft 100 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was 101, heart rate was 103, blood pressure was
114/60 (on Neo-Synephrine and Levophed). Intubated on
ventilatory with settings of synchronized intermittent
mandatory ventilation 600 X 12, FIO2 of 100% pressure
support, a positive end-expiratory pressure of 5, saturating
100%. In general, intubated, opened her eyes, was trying to
speak. Neck was supple. The patient had a right internal
jugular central line in place. Chest revealed coarse breath
sounds bilaterally. Cardiovascular revealed tachycardic, a
regular rate and rhythm. No murmurs, rubs or gallops. The
abdomen was soft, protuberant, and nontender on palpation.
Extremity examination revealed mild edema. Neurologic
examination revealed the patient was intubated, moved all
extremities.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories upon
presentation revealed white blood cell count was 10.3,
hematocrit was 34.4, platelets were 150. Chemistry panel
revealed sodium was 136, potassium was 4, chloride was 104,
bicarbonate was 13, blood urea nitrogen was 36, creatinine
was 1.6, blood glucose was 229. Creatine kinase was 38.
Troponin was less than 0.3. Calcium was 8.8, magnesium
was 1.1, phosphorous was 2.6. Anion gap was 19. Arterial
blood gas upon presentation to the Intensive Care Unit was
7.32, PCO2 was 34, PAO2 was 327.
HOSPITAL COURSE: Ms. [**Known lastname 17832**] was admitted to the Medical
Intensive Care Unit and was cared for by the Medical
Intensive Care Unit team.
1. PULMONARY: The patient was kept on ventilatory support
throughout her entire Intensive Care Unit course, and no
weaning was performed as she had required respiratory
support.
2. HYPERTENSION: The patient was started on chemical
pressors and subsequently maxed out on vasopressin, Levophed,
and Neo-Synephrine. Despite the use of multiple chemical
pressors, her blood pressures continued to drift downward.
3. INFECTIOUS DISEASE: The patient had persistent fevers,
and leukocytosis, and bandemia. Blood cultures and urine
cultures subsequently initially revealed preliminary
high-gram positive cocci. Suspicion of vancomycin-resistant
enterococcus was high. The patient was started on linezolid,
ceftazidime, and metronidazole for treatment empirically.
The patient's was evaluated with an abdominal CT scan to
evaluate for intra-abdominal catastrophe and did not show any
free air or perforations.
4. RENAL: With regard to the patient's renal status, the
patient's creatinine continued to rise without any urine
output. The patient was oliguric from her hypotension and
sepsis.
Despite maximal supportive therapy with chemical pressors and
mechanical ventilation, the patient persisted to have
worsening sepsis. The patient's metabolic status worsened
with worsening acidosis; and by laboratories began to have
disseminate intravascular coagulation. Zigris protein C was
initiated within 12 hours upon presentation; however, the
patient did not improve with the initiation of this
medication.
After a lengthy discussion with the family, the decision was
made to withdraw chemical pressor support. The patient was
started on a Fentanyl drip, and the patient expired minutes
after withdrawal of chemical pressors.
Upon presentation and evaluation, the patient was not
responsive to noxious stimuli. The patient had no breath
sounds or heart sounds. The pupils were fixed and dilated in
the midposition. She had no reflexes. The patient was
pronounced dead on [**2103-8-16**] at 1305.
DISCHARGE DIAGNOSES:
1. Sepsis.
2. Vancomycin-resistant enterococcus bacteremia.
3. Vancomycin-resistant urinary tract infection.
4. Acute renal failure.
5. Hypotension secondary to sepsis.
6. Non-ST-elevation myocardial infarction.
7. Respiratory failure.
8. Severe metabolic acidosis secondary to sepsis.
9. Hypocalcemia.
10. Anion gap acidosis.
11. Type 2 diabetes mellitus.
12. Hypercholesterolemia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 5588**]
MEDQUIST36
D: [**2103-8-16**] 13:56
T: [**2103-8-22**] 10:51
JOB#: [**Job Number 43325**]
Admission Date: [**2103-8-14**] Discharge Date: [**2103-8-16**]
Date of Birth: [**2026-8-11**] Sex: F
Service: ICU
NOTE: Dictation ended after 0.3 minutes.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 5588**]
MEDQUIST36
D: [**2103-8-15**] 13:44
T: [**2103-8-22**] 11:21
JOB#: [**Job Number 43326**]
|
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"401.9",
"584.9",
"592.0",
"038.9",
"276.2",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"56.31",
"56.0",
"38.93",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
6238, 7370
|
2352, 4046
|
4064, 6216
|
161, 1677
|
1700, 2325
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,069
| 187,091
|
19589
|
Discharge summary
|
report
|
Admission Date: [**2188-1-12**] Discharge Date: [**2188-1-23**]
Date of Birth: [**2126-12-23**] Sex: F
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 61 year old female
with longstanding diabetes mellitus and known cerebrovascular
accident who presented to an outside hospital for a two week
history of shortness of breath. Tests performed in the
outside hospital revealed electrocardiogram changes in lead
2, 3 an AVF consistent with an inferior myocardial
infarction. Laboratory data done at that time revealed an
elevated troponin at 16.7. The patient did not complain any
of any chest pain, nausea, or arm tingling. The patient was
transferred from the outside hospital to [**Hospital6 1760**] for a cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Pancreatitis.
3. Hiatal hernia.
4. Cardiovascular accident in [**2174**], two times in [**2177**].
5. Hypercholesterolemia.
6. Status post cholecystectomy.
7. Status post right breast lumpectomy.
8. Status post right carotid artery endarterectomy.
9. Depression.
10. Morbid obesity.
11. Congestive heart failure.
MEDICATIONS ON ADMISSION:
1. Insulin morning dose 50 units NPH, 15 units regular,
evening dose 15 units NPH, 6 units regular.
2. Lipitor.
3. Nexium.
4. Lasix 40 mg p.o. q.d.
5. Zoloft.
6. Albuterol prn.
7. Aspirin 81 mg p.o. q.d.
8. Zetia 10 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Negative for alcohol, drugs and very
distant, 20 years, tobacco use.
REVIEW OF SYSTEMS: The patient denied any fevers, chills,
nausea, vomiting, chest pain, jaw pain, arm pain or
diaphoresis. The patient did endorse that she had had
longstanding bilateral lower extremity edema and that she had
to sleep on three pillows at night in order to breath
comfortably.
PHYSICAL EXAMINATION: On physical examination the patient
was afebrile, 98.3, blood pressure 108/60, pulse 78,
breathing 18 times per minute, 98% on 2 liters of nasal
cannula. In general, she was an obese white female,
uncomfortable in bed, alert and oriented times three but in
no apparent distress. Head, eyes, ears, nose and throat
examination, moist mucous membranes, pupils were equal, round
and reactive to light and anicteric. Neck examination:
Obese, no jugulovenous distension was visualized. Lungs:
Even, unlabored breathing, clear to auscultation bilaterally.
Cardiac examination: Very distant, S1 and S2, no murmurs,
rubs or gallops noted. Abdominal examination: Obese, soft,
nontender, nondistended. No hepatosplenomegaly. Extremity
examination, 1 to 2+ pitting edema in the bilateral lower
extremities. Positive venostatic changes. Extremities were
warm, dry and well perfused.
LABORATORY DATA: Pertinent laboratory data on admission
revealed white count 9.8, hematocrit 37.2, platelets 343.
Chem-7 sodium 137, potassium 5.0, chloride 101, bicarbonate
26, BUN 29, creatinine 1.2, glucose 282. PT 14.4, PTT 67.6,
INR 1.4. Urinalysis was performed which showed 21 to 50
white blood cells, few bacteria, 1000 glucose. Creatinine
kinase 217, CKMB 10, MVI 4.6, troponin 0.33.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service with the attending being Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 2031**]. The patient
underwent the cardiac catheterization on [**2188-1-14**].
The results of the catheterization are as follows:
1. Severe vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
3. Dominant right coronary artery had diffuse 80 to 90%
stenosis with an 80% posterior descending artery lesion. The
LMDA had a 70 to 80% disease of the distal portion of the
vessel. The left circumflex had a diffuse 80% disease with
minimal disease in the obtuse medial branches. Resting
hemodynamics revealed severely elevated left-sided pressures
of 38 mm of mercury. The left ventriculography was deferred
during this examination.
The left ventricular systolic function was determined to be
approximately 55%. Following the cardiac catheterization the
admitting team asked for Cardiothoracic Surgery consult, for
possible coronary artery bypass grafting.
Following the cardiac catheterization the patient was
admitted to the Cardiac Care Unit due to the fact that she
had an intra-arterial balloon pump inserted during the
catheterization. Inside the unit the patient was maintained
on Lasix, Nitroglycerin drip, Lipitor, heparin drip. The
patient was placed on Levaquin 500 mg p.o. q.d. for treatment
of the suspected urinary tract infection.
On [**2188-1-15**], the patient underwent a coronary artery
bypass grafting times four. She had her left internal
mammary artery to left anterior descending, saphenous vein
graft to obtuse marginal, saphenous vein graft to diagonal,
saphenous vein graft to the posterior descending artery. The
cross-clamp time was 94 minutes. The coronary bypass time
was 160 minutes. The procedure was performed by Dr. [**Last Name (STitle) 1537**] and
assisted by Dr. [**Last Name (STitle) 8420**]. The patient tolerated the
procedure well and there were no complications during the
surgery. Following the procedure the patient was transferred
to the Cardiac Surgery Recovery Unit on Milrinone and
Neo-Synephrine drips. The patient was atrially paced at 90
beats/minute.
On postoperative day #1 the patient was maintained intubated.
She continues to be sedated with Propofol. The patient was
also in insulin, Neo-Synephrine and Milrinone drips. The
patient was continued to be atrially paced at 90 with good
blood pressure and cardiac index. The Milrinone was slowly
weaned as well as the Neo-Synephrine. They were unable to
wean her off the vent secondary to low carbon dioxide
titrated with increased FIO2 being required.
On postoperative day #2, the patient remained sedated with a
slow wean due to the fluid overload. The patient responded
to voice when the Propofol had weaned down. The Propofol was
eventually completely weaned off by the early morning. The
patient remained on the Neo-Synephrine drip for second day
blood pressure within acceptable limits. FIO2 was titrated
down to 50% at this time. The IABP was turned off and
removed on this day. By postoperative day #3 the patient
only remained on the Milrinone, Neo-Synephrine and insulin
drip. Her FIO2 was down to 40% and the patient was
spontaneously breathing above the ventilation rate. From the
cardiac standpoint the Neo-Synephrine continued to be weaned
down. Her cardiac index remained approximately 2.0. The
patient did receive 1 unit of packed red blood cells for a
low hematocrit at that time.
On postoperative day #4, the patient remained atrially paced
at 90 with rare ectopy. The patient was extubated early this
morning which was complicated by approximately one hour of
apnea. The patient had difficulty, was unable to cough and
was unable to adequate clear her secretions.
Cardiovascularly, the patient's Milrinone was weaned
completely off with her cardiac index at 3.0. Her Swan was
removed and the port was capped. The Neo-Synephrine was
additionally weaned to off. The patient had been out of bed
to chair several times during the day and was able to
tolerate that without any difficulty. The patient was seen
by physical therapy for an evaluation and it was determined
at this time that the patient would most likely be needing to
go to an Acute Rehabilitation Facility following her
discharge from the hospital.
On postoperative day #5, the patient was transferred out of
the Cardiac Surgery Recovery Unit down to the surgical floor.
The patient continued to be paced at 90 with an underlying
rhythm of 80s and sinus rhythm with occasional premature
atrial contractions. The patient's systolic blood pressure
while paced remained greater than 100 but would dip down into
the mid 80s when she was not paced. The patient was able to
produce an adequate cough and clear her lungs producing a
thick white sputum. The patient continued to use Albuterol
inhalers and was able to maintain her oxygen saturations at
greater than 95% on 2 liters of nasal cannula. The patient
was able to ambulate but needed assistance while doing so.
The patient had very limited activities, with shortness of
breath easily after minimal exertion.
While on the surgical floor the patient continued to do well.
The patient's diet was advanced as tolerated. The patient
continued to be seen and evaluated by physical therapy. The
patient continued to do well with physical therapy and was
able to ambulate independently for short distances but needed
assistance for distances over about 10 yards. The patient
continued to have adequate diuresis. By postoperative day
#8, it was determined by the [**Hospital 228**] medical team that the
patient was well enough to go to a rehabilitation facility at
this time. The patient's pacing wires were removed.
PHYSICAL EXAMINATION ON DISCHARGE: The patient generally was
alert and oriented in no apparent distress. Cardiovascular:
Regular rate and rhythm, no murmurs, rubs or gallops
detected. Lungs, even unlabored breathing, clear to
auscultation bilaterally, while on 2 liters of nasal cannula.
Abdominal examination: Obese, soft, nontender, nondistended,
no hepatosplenomegaly was noted. Extremities: Bilateral
lower extremity edema, 2+ with chronic venous stasis changes
noted bilaterally. Her incision was clean, dry and intact.
Staples were present. She was afebrile, temperature maximum
was 99.5, pulse 74 and sinus. Blood pressure was 120/59,
breathing 94% on 2 liters.
LABORATORY DATA: On discharge complete blood count was 10.9,
hematocrit 28.1, platelets 403. Chem-7 sodium 141, potassium
4.3, chloride 103, bicarbonate 31, BUN 35, creatinine 0.9,
glucose 197.
DISCHARGE DISPOSITION: The patient will be discharged to an
acute rehabilitation facility. The patient was instructed to
follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 53107**] in
one to two weeks. The patient was also advised to follow up
with Dr. [**First Name (STitle) 2031**] in approximately two to three weeks. The
patient was asked to return to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**], her
cardiothoracic surgeon in four weeks. The patient was
advised to please call to make these appointments.
DISCHARGE CONDITION: The patient was discharged in good
condition: Afebrile, ambulating short distances
independently, pain well-controlled on oral medications,
tolerating her diet without any difficulty.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Enteric coated Aspirin 325 mg p.o. q.d.
4. Bisacodyl 10 mg p.r. prn constipation
5. Dilaudid 2 to 4 mg p.o. q. 3-4 hours prn
6. Sertraline 50 mg p.o. q.d.
7. Lasix 40 mg q.d. times seven days
8. Potassium chloride 40 mEq q.d. times seven days
9. The patient will be discharged on 2 liters of nasal
cannula oxygen.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting.
2. Status post cardiac catheterization.
3. Diabetes mellitus.
4. Pancreatitis.
5. Hiatal hernia.
6. Cerebrovascular accident times three.
7. Hypercholesterolemia.
8. Status post cholecystectomy.
9. Status post right lumpectomy.
10. Status post right carotid endarterectomy.
11. Depression.
12. Obesity.
13. Congestive heart failure.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 846**]
MEDQUIST36
D: [**2188-1-23**] 12:28
T: [**2188-1-23**] 12:44
JOB#: [**Job Number 53108**]
cc:[**Last Name (NamePattern4) 53109**]
|
[
"250.00",
"599.0",
"272.0",
"278.00",
"593.9",
"428.0",
"401.9",
"410.71",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"37.61",
"36.15",
"99.03",
"97.44",
"39.61",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9847, 10420
|
10442, 10628
|
10651, 11039
|
11060, 11757
|
1215, 1491
|
3195, 8968
|
1897, 3177
|
8983, 9823
|
1598, 1874
|
174, 196
|
225, 819
|
841, 1189
|
1508, 1578
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,975
| 151,152
|
40838
|
Discharge summary
|
report
|
Admission Date: [**2104-6-27**] Discharge Date: [**2104-7-7**]
Date of Birth: [**2052-7-29**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
R parietal craniotomy for tumor
History of Present Illness:
51F who was found down at work having a seizure. Patient works
at [**Hospital6 2561**] and was brought to the emergency
department there for evalaution, She recieved 1 gram of Keppra
as well as benzos to stop her seizure. When she was found she
had a forced Right gaze and was not moving her left side. She
had a CT
of the brain at [**Last Name (un) 1724**] which showed a right sided brain lesion. She
was subsequently transferred to [**Hospital1 18**] for further evalaution and
management. She is intubated upon arrivla and moving
spontaneously.
Past Medical History:
denies
Social History:
denies T/E/D abuse. Haitian creole speaking. Works at [**Hospital1 **] in housekeeping
Family History:
nc
Physical Exam:
Gen: intubated, agitated
HEENT: Pupils: PERRL EOMs unable to asses
Neck: hard cervical collar, Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm to
1mm bilaterally.
III-XII: unable to assess
Motor: moves all extremities spontaneously, does not follow
commands
Sensation: UTA
Toes upgoing bilaterally
Coordination: UTA
PHYSICAL EXAM UPON DISCHARGE:
non-focal
incision- dissolving sutures, well healing
Pertinent Results:
CT:Right sided brain lesion
[**2104-6-27**] 02:30AM GLUCOSE-112* UREA N-9 CREAT-0.7 SODIUM-150*
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-27 ANION GAP-16
[**2104-6-27**] 02:30AM CK(CPK)-144
[**2104-6-27**] 02:30AM CK-MB-3 cTropnT-<0.01
[**2104-6-27**] 02:30AM CALCIUM-8.9 PHOSPHATE-2.5* MAGNESIUM-1.9
[**2104-6-27**] 02:30AM WBC-6.5 RBC-4.13* HGB-11.3* HCT-33.2* MCV-80*
MCH-27.4 MCHC-34.1 RDW-18.3*
[**2104-6-27**] 02:30AM NEUTS-73.6* LYMPHS-20.0 MONOS-5.6 EOS-0.4
BASOS-0.4
[**2104-6-27**] 02:30AM PLT COUNT-324
[**2104-6-27**] 02:30AM PT-13.9* PTT-21.1* INR(PT)-1.2*
MRI Brain [**2104-6-27**]: Solitary hemorrhagic lesion within the right
temporal lobe. The differential diagnosis includes a hemorrhagic
mass (such as a solitary hemorrhagic metastasis), cavernoma, or
sequela of amyloid angiopathy or coagulopathy. A followup MRI
following resolution of the hemorrhage is necessary to further
characterize the underlying lesion.
CT Torso [**2104-6-28**]: 1. Two small lesions in the liver most
consistent with cysts. This can be confirmed by abdominal
ultrasound. 2. Hyperdense material within the gallbladder may
correspond to the polyps or debris. This could also be confirmed
by abdominal ultrasound. 3. A 7.1-cm lesion in the superior
portion of the uterus may correspond to the fibroid but further
evaluation is recommended by pelvic ultrasound. 4. 1.2-cm
hypodense lesion in the posterior portion of the left thyroid
lobe. Further evaluation is recommended by thyroid ultrasound.
Pap smear [**2104-6-30**]: AT LEAST HIGH GRADE SQUAMOUS INTRAEPITHELIAL
LESION
Thyroid U/S [**2104-6-30**]: Spongy nodule seen in the left lobe of the
thyroid. Based on ultrasound criteria, this nodule does not
demonstrate any worrisome features and a routine followup
ultrasound could be performed in one year.
Abdominal U/S [**2104-6-30**]: 1. Two simple hepatic cysts. 2. The
gallbladder is entirely filled with small shadowing gallstones.
Pelvic U/S [**2104-6-30**]: 1. Ill-defined infiltrative appearing
cervical mass, which is concerning for malignancy. A GYN consult
is suggested and this mass could be further assessed with pelvic
MRI in conjunction with pap smear / biopsy. 2. Uterine mass with
ultrasound appearance compatible with a fibroid. 3. Trace of
fluid in the endometrial stripe with borderline endometrial
thickness of 5 mm. No adnexal mass identified.
MRI pelvis [**2104-7-3**]: 1. 3.2 cm mass involving the left side of the
cervix, consistent with cervical malignancy. MRI stage 1B1. 2.
1.8 cm left ovarian cyst which appears simple by MR but requires
follow up if patient is postmenopausal.
Brief Hospital Course:
Pt was admitted to the ICU and was monitored closely. She
remained stable. She underwent MRI of the brain and was then
able to tolerate extubation. Brain MRI demonstrated an
enhancing R parietal lesion. Susequently a C/A/P Ct with and
without contrast was obtained which demonstrated multiple
lesions in liver, uterus, gallbladder, and thyroid. On [**6-30**] an
a/p and thyroid ultrasound demonstrated a large cervical mass
and benign liver/thiroid and cholelithiasis. OB/GYn was
consulted regarding cervical mass and further management. On
[**7-1**] They recommended an MRI pelvis which was ordered. The
patient developed left hemiparesis in the early AM which was
thought was due to seizure activity. It responded to ativan and
a Head CT was stable. She was started on dilantin in addition to
her Keppra.
On [**7-2**] she remained neurologically stable without seizure
activity. On [**7-3**] an MRI fo the pelvis was performed and GYN
recommended biopsy due to the pap smear result of high grade
dysplasia. They would like to perform this after the brain
lesion resection.
On [**7-4**], she underwent R craniotomy and mass resection. Surgery
was without complication and she tolerated it well.
Over the weekend, patient was transferred to the floor. She was
seen to be tachycardic to 110 and recieved a 250cc bolus.
On [**7-7**], patient was neurologically stable, GYN oncology was
consulted for cervical mass. They consented her for a biopsy and
she was discharged home to follow up as an outpatient for the
procedure.
Medications on Admission:
unknown
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets 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).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule
PO QAM (once a day (in the morning)).
8. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO QPM (once a day (in the evening)).
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for PAIN.
Disp:*60 Tablet(s)* Refills:*0*
11. dexamethasone 2 mg Tablet Sig: taper Tablet PO as directed
for 5 days: 3mg Q8hrs on [**7-7**], 2mg Q8hrs on [**7-8**], 1mg Q8hrs on
[**7-9**], 1mg Q12hrs on [**7-10**].
1mg Qday on [**7-11**] then discontinue.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right parietal brain lesion
Seizures
Cervical Mass
Cholelithiasis
Thyroid Nodule
Benign Liver Cysts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If 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**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
* You will be contact[**Name (NI) **] by GYN [**Name (NI) **] office for date
and time of outpatient procedure. If you have any questions,
please contact their office, their phone number is [**Telephone/Fax (1) 5777**].
Follow-Up Appointment Instructions
??????Please return to the office in [**8-3**] days(from your date of
surgery) 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 6 weeks.
You also have follow up with the following:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2104-8-18**] 9:30
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2104-8-18**]
8:35
Completed by:[**2104-7-7**]
|
[
"780.39",
"241.0",
"573.8",
"348.5",
"622.10",
"342.00",
"574.20",
"620.2",
"789.39",
"401.9",
"348.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"91.46"
] |
icd9pcs
|
[
[
[]
]
] |
7188, 7194
|
4342, 5877
|
315, 348
|
7338, 7338
|
1694, 4319
|
9397, 10465
|
1076, 1080
|
5935, 7165
|
7215, 7317
|
5903, 5912
|
7489, 9374
|
1095, 1305
|
268, 277
|
1621, 1675
|
376, 926
|
1347, 1591
|
7353, 7465
|
948, 956
|
972, 1060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,937
| 154,302
|
29783
|
Discharge summary
|
report
|
Admission Date: [**2133-3-3**] Discharge Date: [**2133-3-4**]
Date of Birth: [**2092-7-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
PEGJ occlusion and respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
40 yo M with IPF, s/p double lung tx [**2128**], h/o recurrent
pneumonia, chronic rejection and obliterative bronchiolitis,
polymiositis, recent hospitalization for acute on chronic resp
failure and multilobar pneumonia requiring chest tubes and PEJ
placement by IR (discharged on [**2133-2-26**]) presenting from Radius
[**Hospital 4094**] Rehab for PEGJ occlusion. He was transported from
rehab to [**Hospital1 18**] ED using bag ventilation and was found to be
lethargic and disoriented upon arrival to the ED.
.
In the ED his vitals were temp 101, HR 117, BP 210/105, RR 33,
O2sat 89-95% and his ABG was 7.0/180/386. He was then placed on
a ventilator in the ED and a repeat ABG was 7.24/89/71/40. His
PEJ was repositioned by surgery in the ED without difficulty and
is ready to use. He was brought to the MICU for resolution of
his respiratory distress. A repeat ABG in the MICU was
7.24/94/70. His ventilator settings are TV300 RR20 PEEP8 FiO2
40. It appears that he is now at his baseline with regards to
his ABG.
.
In the MICU his mental status is much improved. He is alert and
oriented with no other complaints. He denies any fever, chills,
nausea, vomiting, chest pain, or shortness of breath. He does
not feel disoriented or that his breathing is impaired. He
feels hungry.
Past Medical History:
Chronic resp failure/ vent dependent since [**2132-2-3**]
Chronic bronchitis
Status post bilateral lung tranplant in [**2128**] [**3-6**] idiopathic
pulmonary fibrosis complicated by chronic rejection and frequent
aspiration pneumonia
idiopathic pulmonary fibrosis since [**2122**]
status post tracheostomy placement in [**2132-2-3**]
esophageal dysmotility
GERD
HTN
Paroxysmal atrial fibrillation
hyperlipidemia
DM II
sacral decubitus ulcer now healed
severe anxiety
depression
anemia of chronic disease
pancreatitis
chronic renal insufficiency
Social History:
Lives at [**Hospital 671**] Rehab, wife is supportive. Has two sons. [**Name (NI) **]
drinking, smoking, drug use.
Family History:
NC
Physical Exam:
Gen: well developed, well nourished, trach ventilation in tact
HEENT: NC, AT, MMM, PERRL, EOMI
CV: RRR nl S1, S2
Lungs: coarse insp and expir breath sounds, no focal area of
consolidation, no wheezing
Abd: soft NT ND + BS, PEJ tube site c/d/i
Ext: 2+ pulses in all four, nl sensation, able to move all 4
extremities with 4/5 strength.
Neuro: alert, oriented x 3, CN 2-12 intact
Pertinent Results:
[**2133-3-3**] 12:16PM TYPE-ART RATES-/24 TIDAL VOL-350 O2-100
PO2-386* PCO2-180* PH-7.00* TOTAL CO2-48* BASE XS-6 AADO2-162
REQ O2-36 -ASSIST/CON INTUBATED-INTUBATED
[**2133-3-3**] 03:28PM TYPE-ART PO2-71* PCO2-89* PH-7.24* TOTAL
CO2-40* BASE XS-7 -ASSIST/CON
[**2133-3-3**] 06:41PM TYPE-ART TEMP-37.6 RATES-20/ TIDAL VOL-300
PEEP-8 O2-40 PO2-70* PCO2-94* PH-7.24* TOTAL CO2-42* BASE XS-8
-ASSIST/CON INTUBATED-INTUBATED
[**2133-3-3**] 10:13PM LACTATE-0.8
[**2133-3-3**] 10:13PM TYPE-ART PO2-88 PCO2-72* PH-7.29* TOTAL
CO2-36* BASE XS-4
[**2133-3-3**] 10:19PM CALCIUM-7.6* PHOSPHATE-2.5* MAGNESIUM-1.5*
[**2133-3-3**] 10:19PM CK-MB-NotDone cTropnT-<0.01
[**2133-3-3**] 10:19PM CK(CPK)-26*
[**2133-3-3**] 10:19PM GLUCOSE-137* UREA N-31* CREAT-1.1 SODIUM-147*
POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-29 ANION GAP-10
Brief Hospital Course:
40 yo male vent dependent with PEGJ occlusion requiring transfer
to the ED for eval by gen surgery and en route developing
respiratory distress with hypercarbia and acidosis.
.
# Severe respiratory acidosis: in the ED his ABG showed a ph of
7.0 with a CO2 of 180. On his recent admission, his CO2 was
found to be as high as 200 and it seems that his baseline ABG is
7.2's/70's/100.
His repeat ABG's while on the ventilator at his normal settings
in the ED and in the MICU have returned to his normal baseline;
otherwise, continued vent settings and nebs from rehab.
.
# Infection: in ED patient was found to have temp of 101 with
WBC of 30; afebrile and WBC decreasing on admission to the MICU.
on discharge from previous hospitalization([**2-26**]) WBC was 9 in
the setting of being in respiratory distress. At rehab was on
meropenem, Bactrim and Flagyl. CXR in ED showed Patchy opacity
within the right base appears slightly more prominent when
compared to prior radiographs and may be related to underlying
fluid overload; however, superimposed infectious process cannot
be excluded. CXR showed a question of worsening pneumonia; U/a
was negative; blood culture and sputum culture were NGTD; LFT,
amylase, lipase normal; continued bactrim, flagyl, meropenem
plan for 1 more week to complete course.
.
# PEGJ repositioning: main reason for transfer to [**Hospital1 **] was for
repositioning/ occlusion of his PEJ. currently working
well-maintained on tube feeds.
.
# Altered mental status overnight: probable [**3-6**] multiple
sedating medications- Resolved o/n; nl EKG, trop, electrolytes,
ABG; discussed with patient in AM of HD1 when alert and he says
that he feels back to baseline.
.
#Anxiety and depression: continued seroquel, clonazepam,
morphine prn
.
# Lung transplant: continued cellcept, tacrolimus, nebs
.
# DM type II: tightened ISS, max glucose 220
.
# HTN: continue HCTZ, metoprolol
.
FEN: PEJ in place, TF at 50/ hr, replete lytes
.
Ppx: SC heparin, pneumoboots, PPI
.
Access: Right PICC, left PIV
Medications on Admission:
Lansoprazole 30 mg Tablet PO DAILY
Ipratropium Bromide
Trimethoprim-Sulfamethoxazole 40-200 PO DAILY
Mycophenolate Mofetil 1000 mg TabletBID (2 times a day).
Atorvastatin 10 mg PO DAILY
Citalopram 40 mg Tablet PO DAILY
Albuterol
Bisacodyl 10 mg Tablet PO DAILY
flagyl 500 TID
Clonazepam 0.5 mg PO QHS
Quetiapine 50 mg Tablet PO BID
Prednisone 20 mg PO DAILY
Docusate Sodium 100 mg PO BID
Senna
Zolpidem 5 mg PO HS
Metoprolol Tartrate 100 mg PO TID
Hydrochlorothiazide 25 mg PO DAILY
Morphine Sulfate 2-6 mg IV Q3-4H:PRN abdominal pain
Insulin sliding scale
Tacrolimus 5 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times
a day): In total should receive tacrolmius 9 mg [**Hospital1 **].
Tacrolimus 1 mg Capsule [**Hospital1 **]: Four (4) Capsule PO twice a
day: In total should receive Tarolimus 9 mg [**Hospital1 **] .
Discharge Medications:
1. Morphine Sulfate 2 mg IV Q4H:PRN pain
2. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
3. 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.
4. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED).
5. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
9. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO
BID (2 times a day).
10. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Citalopram 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
14. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day).
15. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
16. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
17. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
18. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
19. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
20. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Nine (9) Capsule PO BID (2
times a day).
21. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
22. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
23. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous every
six (6) hours for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
blocked feeding tube
respiratory distress/ pneumonia
Discharge Condition:
stable and improving
Discharge Instructions:
You will be discharged back to the Rehab facility today. Your
PEGJ tube was fixed in the emergency department and you were
kept overnight in the ICU to monitor your respiratory status on
the ventilatory. You seem to be at your baseline and will be
sent home today. You continue to have a pneumonia seen on chest
xray and you should continue all three antibiotics that you were
recently prescribed on discharge on [**2133-2-26**].
If your breathing should worsening, develop a fever, chills,
nausea, vomiting, headache, chest pain, abdominal swelling or
pain, you should call your PMD or return to the ED immediately.
Additionally, if you require transport by ambulance in the
future, you should request to be on a ventilator.
Followup Instructions:
Follow up with your PMD at [**Hospital 671**] rehab to continue to monitor
your pneumonia.
You should follow up with the lung specialists at [**Hospital1 3372**] Center for Chest Disease.
Division of Thoracic Surgery
[**Hospital6 1708**]
[**Last Name (NamePattern1) 14305**]
[**Location (un) 86**], [**Numeric Identifier 6425**]
Phone: ([**Telephone/Fax (1) 71275**]
|
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icd9cm
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[
[
[]
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[
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[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,010
| 176,608
|
40123
|
Discharge summary
|
report
|
Admission Date: [**2185-1-7**] Discharge Date: [**2185-1-15**]
Date of Birth: [**2106-8-5**] Sex: F
Service: MEDICINE
Allergies:
Coumadin / Penicillins / IV contrast / Sulfa (Sulfonamide
Antibiotics) / Prednisone / Latex
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Hemoptysis/septic arthritis/ NSTEMI
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
78 yo female with h/o HTN, Type II DM, CAD s/p remote LAD stent,
COPD, and recent right total knee replacement complicated by
infected hardware s/p removal transferred from OSH for further
management of hemoptysis and NSTEMI.
Patient was admitted to [**Hospital3 **] Hospital in late [**Month (only) **] with
right knee septic arthritis following a right total knee
replacement, cultures grew Group B Strep. Hardware was removed
at [**Hospital 1562**] hospital on [**2184-12-17**], replaced by antibiotic spacer.
Per report, the patient had bilateral DVTs on [**2184-12-15**], noted
again on LENIs from [**2185-1-1**]. At this time, it appears the
patient was on prophylactic dose of enoxaparin. Patient was
then discharged to rehab following hardware removal. Per
report, she developed respiratory distress on [**2185-1-1**], with
hypoxia and wheezing. No aspiration event was witnessed. There
was a question of excess sedation. After being re-admitted to
[**Hospital 1562**] hospital, she was initially treated with BiPAP and
nebulizers, with good effect. IV fluids were given for
hypotension and tachycardia. She had a second episode of
respiratory distress, and was transferred to the ICU for further
management. She then underwent diuresis, and was placed on
BiPAP. She was intubated on [**2185-1-3**]. A Swan-Ganz catheter was
placed on [**2185-1-4**] for hemodynamic monitoring in the setting of
possible cardiogenic shock. She was then started on levofloxacin
and clindamycin for aspiration pneumonia, and was transitioned
to vancomycin, cefepime, and metronidazole. She also received
pulse dose methylprednisolone for possible COPD exacerbation.
Over past few days, vent wean has been complicated by low minute
ventilation and airway secretions.
Today, patient had episode of hemoptysis, with 50-100 cc of
bright red blood suctioned through ET tube. Bronch showed
lesions in left main stem bronch near second carina, one
suspicious for an eroding broncholith. A bleeding lesion was
injected with epinephrine and iced saline, with hemostasis.
Patient was then transferred via [**Location (un) 7622**] directly to ICU for
further management.
Upon arrival to the ICU, patient was intubated, alert, on
minimial sedation. She complained of pain in her right knee,
and denied any other pain.
Past Medical History:
COPD
? OSA
HTN
CAD s/p stent to LAD in [**2174**]
left subclavian occlusion
critical left internal carotid stenosis s/p CEA
Type II DM
hypothyroidism
GERD
DVT in bilateral [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 88154**]
Social History:
Lives in nursing home recently. no history of recent tobacco or
alcohol use recently.
Family History:
non-contributory
Physical Exam:
VS: T 98 HR 70 BP 115/41 100% FiO2 30%, PEEP 5
GEN: elderly female, NAD, alert
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, JVD to angle of
jaw, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout, although
dimished in axillae
CV: RR, S1 and S2 wnl, no r/g. II/VI systolic murmur at LUSB,
with radiation to right carotid
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: fungal rash in inguinal folds
NEURO: alert. 1+D TR's-patellar and biceps
Pertinent Results:
Admission labs:
[**2185-1-8**] 12:29AM BLOOD WBC-7.3 RBC-3.44* Hgb-9.9* Hct-30.5*
MCV-89 MCH-28.8 MCHC-32.4 RDW-16.1* Plt Ct-264
[**2185-1-8**] 12:29AM BLOOD PT-14.8* PTT-24.0 INR(PT)-1.3*
[**2185-1-8**] 12:29AM BLOOD Glucose-120* UreaN-33* Creat-0.9 Na-141
K-4.0 Cl-97 HCO3-32 AnGap-16
[**2185-1-8**] 12:29AM BLOOD ALT-10 AST-27 CK(CPK)-66 AlkPhos-47
TotBili-0.5
[**2185-1-8**] 12:29AM BLOOD CK-MB-2 cTropnT-0.44*
[**2185-1-8**] 12:29AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8
[**2185-1-8**] 02:06AM BLOOD Type-ART Rates-/14 Tidal V-500 PEEP-5
FiO2-30 pO2-112* pCO2-37 pH-7.57* calTCO2-35* Base XS-11
-ASSIST/CON Intubat-INTUBATED
[**2185-1-8**] 02:06AM BLOOD Lactate-1.0
Cardiac Enzymes
CPK ISOENZYMES CK-MB cTropnT proBNP
[**2185-1-10**] 04:33 2 0.38*1
Source: Line-Right CVL
[**2185-1-9**] 00:31 3 0.51*1
Source: Line-CVL
[**2185-1-8**] 13:33 3 0.55*1
Source: Line-picc
[**2185-1-8**] 07:23 3 0.51*1 [**Numeric Identifier 7260**]*2
Source: Line-central
[**2185-1-8**] 00:29 2 0.44*3
Imaging:
CXR [**1-7**]:
FINDINGS: The tip of the endotracheal tube is 3.5 cm above the
carina. There is a right IJ central venous catheter with distal
lead tip in the proximal SVC. There is a nasogastric tube whose
tip and side port are below the gastroesophageal junction. The
cardiac silhouette is enlarged. There is a left IJ and
subclavian central lumen catheters with the distal lead tip in
the mid SVC. There is prominence of the pulmonary interstitial
markings, compatible with fluid overload. There is left
retrocardiac opacity and a small left-sided pleural effusion.
TTE [**1-10**]:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.2 m/s
Right Atrium - Four Chamber Length: *5.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% >= 55%
Left Ventricle - Stroke Volume: 50 ml/beat
Left Ventricle - Cardiac Output: 3.42 L/min
Left Ventricle - Cardiac Index: *1.65 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 19 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Aortic Valve - LVOT pk vel: 0.80 m/sec
Aortic Valve - LVOT VTI: 16
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2
Aortic Valve - Pressure Half Time: 273 ms
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.11
Mitral Valve - E Wave deceleration time: 192 ms 140-250 ms
TR Gradient (+ RA = PASP): *32 to 34 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 1.0 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderately depressed LVEF. No LV mass/thrombus. No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild AS
(area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild thickening of mitral valve
chordae. No MS. Mild (1+) MR. [Due to acoustic shadowing, the
severity of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Trivial/physiologic pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is moderately to severely
depressed (LVEF= 25-30 %) with infeior, lateral, anterior and
apical hypokinesis to akinesis. No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic valve leaflets are mildly thickened
(?#). There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. 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. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Persantine Stress Test [**2185-1-12**]
IMPRESSION: No anginal symptoms or additional ST segment changes
from
baseline. Nuclear report sent separately.
Nuclear Imaging Status Post Persantine Stress Test [**2185-1-12**]
The image quality is adequate but limited due to soft tissue,
breast, and left
arm attenuation.
Left ventricular cavity size is increased.
Rest and stress perfusion images reveal a predominantly fixed,
moderate
reduction in photon counts involving the entire inferior wall,
and the mid and
basal inferolateral walls.
Gated images akinesis of the entire inferior wall and the mid
and basal
inferolateral walls.
The calculated left ventricular ejection fraction is 29% with an
EDV of 203 ml.
IMPRESSION:
1. Predominantly fixed, large, moderate severity perfusion
defect involving the PDA/LCx territory.
2. Increased left ventricular cavity size. Severe systolic
dysfunction with akinesis of the entire inferior wall and the
mid and basal inferolateral walls.
Knee X-ray [**1-10**]:
FINDINGS: Overlying knee brace obscures the bony detail of the
knee.
Multiple calcifications are seen in the soft tissues. Cement
spacers are
present at the distal femur and proximal tibia. No definite
fractures.
IMPRESSION: Right knee cement spacers.
MICRO DATA: ([**2185-1-8**])
SPUTUM
GRAM STAIN (Final [**2185-1-8**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2185-1-10**]):
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
UCX- yeast
BCX- negative x2
Brief Hospital Course:
Mrs. [**Known lastname 68990**] is a 78 yo female with a PMH significant for CAD s/p
PCI, HTN, HLD, COPD, recent right knee replacement complicated
by septic joint, bilateral DVT s/p IVC filter transferred from
OSH for management of hemoptysis and respiratory failure.
# Hemoptysis- submassive: In the ICU, bronch showed two areas
of ulceration of unclear etiology and a possible polypoid
lesion. No diagnostic or therapeutic intervention performed by
IP. No further hemoptysis. Upon transfer to the floor,
discussion about repeat bronchoscopy to r/o any oozing lesions
prior to starting anticoagulation (for DVT's per below). Went
to IP procedure lab, but IP decided she was too high risk given
recent cardiac pathology (see below). Given her stable HCT and
no further hemoptysis since transfer from OSH, suggested
starting systemic anticoagulation with a heparin gtt and
following up with rigid bronchoscopy under general anesthesia if
repeat bleeding were to occur. Started hepar gtt without issue,
HCT was stable. No further interventions were needed.
She will need a repeat bronchoscopy with biopsy in one month
(when her cardiac issues have stabilized). Interventional
pulmonology has the patient's information, and said they would
contact the patient for arrangement of a follow up appointment.
This was confimred with Dr. [**Last Name (STitle) 88155**] [**Name (STitle) 13470**]. THe patient was
given contact information of the interventional pulmonology
suite at ([**Telephone/Fax (1) 17398**] as well as [**Hospital1 1388**] main line at
[**Telephone/Fax (1) 250**] with the IP fellows pager number at [**Numeric Identifier 88156**] in the
event she has not been contact[**Name (NI) **] within 3 weeks of discharge.
The patient confirmed understanding of this issue prior to
discharge.
# Hypotension/Acute on chronic systolic heart failure: In the
ICU her hypotension was thought to be secondary to acute
systolic heart failure secondary to her NSTEMI and worsening
systolic function. She had no evidence of distributive shock.
Sedation also thought to be contributing. Dobutamine was weaned
upon arrival without difficulty. TTE showed worsening systolic
function with new EF of 25-30% (from baseline of 40%). Upon
transfer to the floors, did not require further diuresis as
physical exam was nt consistent with HF, no sob. Bilateral
lower extremity was present throughout duration of stay thought
to be due to bilateral DVT's. Given depressed EF, will need
follow up evaluation by cardiology to assess the need for
pacemaker placement once HF class can be determined with
activity. Patient claims to have her own cardiologist, but also
given the number of the [**Hospital1 18**] cardiology clinic if she would
like to transition her care to the [**Hospital1 18**] system.
# Respiratory failure: Likely a component of pulmonary edema
from acute systolic heart failure given her improvement with
diuresis. Low suspicion for PNA. PE was a possibility, although
less likely given IVC filter. She was successfully extubated on
[**1-9**]. She had no return of SOB while on the general medical
floors. No further thoracic imaging was done to look for PE as
patient was to receive systemic anticoagulation regardless for
B/L DVT's.
# NSTEMI: Patient was found to have elevated cardiac enzymes
with TnTs peaking at 0.55. BNP 50k, MB flat. No EKG changes.
Cardiology was consulted, but anticoagulation (plavix and
heparin gtt) was held due to hemoptysis due to risk of bleeding.
She was treated with ASA 325 mg daily and started on a statin
and metoprolol. She had a TTE which showed an overall left
ventricular systolic function which was moderately to severely
depressed (LVEF= 25-30 %) with infeior, lateral, anterior and
apical hypokinesis to akinesis (which is worse then her baseline
EF of 40%). Upon transfer to the medical floor, troponin
continued to downtrend. No ekg/telemetry changes were observed.
Had pharmacologic stress test with persantine followed by MIBI.
Stress was negative for EKG changes/anginal symptoms, and MIBI
showed irreversible defect in the PAD/LCx distribution. Given
irreversibility, cath not indiciated and Plavix not indciated
given the duration post NSTEMI. Continued to medically manage
NSTEMI with ASA, metoprolol, lisinopril, and high dose
atorvastatin without issue. Placed back on home fenofibrate
upon discharge (not given as non-formulary in house).
# Bilateral DVT: Patient had an IVC filter placed at an OSH in
mid-[**Month (only) 1096**] per her son. Systemic anti-coagulation was held as
above in setting of hemoptysis, however she was given SC heparin
as prophylaxis. After acute hemorrhaging was ruled out (per
above) was started on heparin gtt. HCT stable on heparin gtt
and tranisitioned to enoxaparin 90 mg [**Hospital1 **] for at least 3 months
of treatment (started anticoagulation [**2185-1-11**]) given provoked
development of DVTs in the setting of orthopedic surgery and
lack of mobility. Will need follow up in 3 months with f/u
lower extremity ultrasounds to assess for dissolution of blood
clots. Should be scheduled by her PCP.
# Septic right knee s/p hardware removal: X-ray of knee showed
hardware (cement spacers) in place. She was continued on
ceftriaxone 2 grams IV daily, with day one of Abx treatment
being [**2185-1-4**]. Will need at 28 days worth of antibiotics with
ortho f/u for hardware replacement once infection has been
deemed cleared. Discharged on pain control with 5 mg oxycodone
q4 hours PRN and oxycontin 10 mg [**Hospital1 **]. Patient's orthopedic
surgeion Dr. [**Last Name (STitle) 46850**] was contact[**Name (NI) **] regarding this issue and faxed
a discharge summary. Patient also provided with Dr.[**Name (NI) 88157**]
contact information.
CHRONIC ISSUES
# DM: continued SSI regimen w/o issue.
.
# GERD: disconitnued home PPI as past duration of therapy for
GERD. Can restart if symptoms of GERD return.
# COPD: Continued albuterol/ipratropium nebs prn without issue.
.
# Contact Precautions: has history of VRE per OSH records.
will need to continue on contact precautions.
Comm: patient, [**Name (NI) **] [**Name (NI) 68990**], [**Telephone/Fax (1) 88158**], home [**Telephone/Fax (1) 88159**].
Code: full (discussed with son [**Name (NI) **], HCP)
PENDING LABS AT DISCHARGE: None
TRANSITIONAL ISSUES: Will need f/u US for DVT reassessment in 3
months (To be completed by PCP). PCP should also affirm
cardiovascular follow up, bronchoscopy follow up by 3/[**2185**].
Orthopedist aware of issues and has also been provided with
copies of hospital course. PCP and orthopedist both faxed
copies of DC summary on [**2185-1-15**]
Medications on Admission:
Medications at rehab:
enoxaparin 30 mg Q12
gabapentin 300 mg TID
metoprolol tartrate 12.5 PO BID
fenofibrate 160 mg daily
Zetia 10 mg daily
Cefazolin 2 gram IV Q8
ASA 81 mg daily
Prilosec 20 mg daily
Vitamin B12 1000 mcg PO daily
Vitamin D3 1000 units PO daily
hydromorphone 2 mg PO Q4H PRN pain
Meds on transfer:
furosemide 40 mg IV Q12
enalapril 0.625 mg IV Q8H
methylprednisilone 20 mg IV Q12
dobutamine gtt
nitro paste 1 inch Q6H
ceftriaxone 2 grams daily
pantoprazole 40 mg IV daily
ASA 81 mg daily
fentanyl gtt
midazolam gtt
linezolid 600 mg x 1 (VRE in urine)
TFs
albuterol/ipratropium nebs Q6H PRN
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
2. insulin lispro 100 unit/mL Solution Sig: per SSI per SSI
Subcutaneous ASDIR (AS DIRECTED).
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation q6hr prn as needed for
shortness of breath or wheezing.
5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation q6h prn.
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for for knee pain.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain: Hold for sedation/ rR<10.
Disp:*qs for rehab Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
16. polyethylene glycol 3350 17 gram/dose Powder Sig: [**1-9**] PO
DAILY (Daily) as needed for constipation: Patient may refuse.
At risk for constipation given need for opiods. Hold if having
regular bowel movements.
17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
18. CeftriaXONE 2 gm IV Q24H Start: In am
19. 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.
20. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation: Hold if
patient is having regular bowel movements.
21. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Hold if patient is having regular bowel movements.
22. Enema Enema Sig: One (1) Rectal [**Hospital1 **] PRN: For
constipation. Can use tap water enemas, soap [**Last Name (un) **] enemas, and
sodium phosphate enemas.
23. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day: hold for
sedation/ RR<10.
Disp:*qs rehab Tablet Sustained Release 12 hr(s)* Refills:*0*
24. zeita Sig: Ten (10) mg once a day.
Discharge Disposition:
Extended Care
Facility:
JML Center
Discharge Diagnosis:
Primary:
Septic Arthritis
Non-ST Elevation Myocardial Infarction
Hemoptysis
Bilateral Lower Extremity Deep Vein Thromboses
Secondary:
Chronic obstrucitve pulmonary disease
Hypertension
Coronary artery disease with stenting of left anterior
descending artery in [**2174**]
Internal carotid stenosis status post coronary artery dissection
Type II Diabetes Mellitus
Gastroesophageal Reflux Disease
Osteoarthritis
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 68990**],
It has been a pleasure taking care of you. You were originally
transferred to [**Hospital1 69**] for
management of multiple medical issues outlined below.
At the previous hospital, you experience a heart attack known as
a "Non-ST Elevation Myocardial Infarction" or "NSTEMI" for
short. It is a heart attack which occurs without changes seen
on an EKG, but is detected by blood tests which tell your
medical team that your heart muscle has been affected. You were
evaluated by cardiologists here that placed you on medication to
optimize your cardiac function (outlined below). During your
stay, you had a "Pharmacologic Stress Test" with a medication
known as "Persantine" which mimics an exercise stress test. You
also had a radionucleotide test to look at the tissue and
function of your heart. The results of these two tests informed
your physicains that having a repeat catherization of the
vessels of your heart would NOT be beneficial at this time.
Thus, you should continue to take your cardiac medication as
prescribed to decrease the risk of having another cardiac event
in the future. Additionally, you will need to follow up with a
cardiologist. You can follow up with your own cardioloigst, or
the number of the cardiology department at [**Hospital1 18**] has been
provided for you to make a follow up appointment at your
convenience.
At the outside hospital, you had an episode of coughing up blood
while you were intubated (this phenomenom is known as
"hemoptysis"). Given this condition, the physicians at [**Hospital1 **] reimaged your airway while you were in the ICU,
and found an ulceration in one of the larger airways (Bronchus
intermedius) with friable mucosa. This was most likely thought
to be due to airway irritation from suctioning while you were
intubated. You had
Prior to coming to [**Hospital1 18**], you had "septic arthritis" after you
right knee replacement. This is a complication that can occur
in patients who experience a knee replacement, which you had.
You had your knee replacement hardware removed, and cement
"spacers" were placed between the bones of your leg for
stability. You will need to continue antibiotic treatment for
at least four weeks, with follow up with your orthopedic surgeon
Dr. [**First Name (STitle) **] to decide when would be the best time for you to
have your knee replacement performed again. Additionally, you
will need to conintue physical rehabilitation to keep the
condition of your muscles up in order to optimize your recovery.
.
You have started many new medications, and some of your home
medications have been changed. Please continue to take your
medications as directed:
Ipratropium Bromide MDI 2 PUFFs inhaled every 6 hours (for COPD)
Albuterol Inhaler 2 PUFF inhaled every 6 hours as needed for
shortness of breath
Lisinopril 2.5 mg orally daily- new cardiac medication (controls
blood pressure, helps heart muscle)
Furosemide 20 mg orally daily (for fluid retention/heart
failure)
Metoprolol Tartrate 25 mg by mouth 2x a day- (cardiac
medication: controls heart rate/blood pressure)
Aspirin 325 mg DAILY
Zetia 10 mg daily (for cholesterol)
Atorvastatin 80 mg DAILY (cardiac medication- controls
cholesterol and improves heart function/reduces risk of
recurrent heart attack) CeftriaXONE 2 gm IV daily (IV
antibiotic for septic arthritis)OxycoDONE (Immediate Release) 5
mg every 3 hours as needed for pain
Oxycontin 10 mg 2x a day- long acting pain medication for basal
pain control
Enoxaparin Sodium 90 mg injections 2x a day (for blood clots in
legs)
Insulin Sliding Scale- for glucose control
.
We have discontinued your Prilosec 20 mg daily (Aka Omeprazole),
a medication typically used for gastric reflux. The duration of
being on this medication was longer than the usual therepeutic
course. Please follow up with your primary care doctor if you
have returning symptoms of reflux including heart burn/sour
taste in the morning.
.
It has been a pleasure taking care of you [**Known firstname **]!!!
Followup Instructions:
You will need to follow up with your primary care doctor. Your
listed PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 70179**]. Please
schedule follow up within 1 week after your discharge form
rehab.
You will need to be seen by a cardiologist given your recent
heart attack. You can follow up with your own cardiologist if
you have one. If you would like to be seen by a [**Hospital1 **] cardiologist, the number to our cardiology clinic is
([**Telephone/Fax (1) 2037**]. While in the hospital, you were seen by [**Name6 (MD) **] [**Name8 (MD) **], MD [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD. You may try to request follow
up with them if you like.
Given your episodes of hemoptysis (coughing up blood), you will
need to follow up with interventional pulmonology for a repeat
bronchoscopy to image your airway. Interventional pulmonology
would like you to be seen for a repeat procedure within 30 days.
They have your information, and will contact you for
arrangement of follow up appointment.
Dr. [**Last Name (STitle) 88155**] [**Name (STitle) 13470**], or one of her colleagues, will be in touch
with you in the following weeks. If you do not hear from this
team within the month, please call the interventional
pulmonology suite at ([**Telephone/Fax (1) 17398**], or you can call
[**Telephone/Fax (1) 250**] and have the number [**Serial Number 88156**] paged to speak with one
of the interventional pulmonology fellows to rectify the issue.
You will need to be followed up by your orthopedic surgeon Dr.
[**Last Name (STitle) 46850**]. Please contact him at [**Telephone/Fax (1) 88160**] at your convenience
regarding the status of your knee and when further interventions
can be performed to replace your knee.
|
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12,167
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30617
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Discharge summary
|
report
|
Admission Date: [**2190-10-17**] Discharge Date: [**2190-10-22**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization and bare metal stent placement
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo F with history of inferior STEMI in [**5-22**]
complicated by hypotension and bradycardia requiring temporary
pacing during RCA stenting who presents with inferolateral
STEMI. She awoke from sleep with severe CP that did not resolve
with 3 NTG and called EMS. Per EMS, she was bradycardic to the
30s requiring atropine enroute.
.
In the ER, she received levophed, dopamine, heparin drip, [**Date Range 4532**]
load, zofran and morphine. Her HR was persistently low
requiring two more doses of atropine. The cath [**Date Range **] was
activated, and she underwent cath showing stent thrombosis of
proximal RCA BMS that was treated with Export thrombectomy, PTA
and stenting with BMS. Her course was complicated by
bradycardia requiring temporary pacer wire placement. She was
weaned off pressors while in the [**Date Range **].
.
In the CCU, she reports feeling much better now. Patient denies
any CP other than last night but her son reports an episode
angina last week that resolved with two NTG.
.
On review of systems, she has a history of CVA and is recovering
from a bout of bronchitis causing cough. She denies any prior
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains or hemoptysis. 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 dyspnea on
exertion, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2186-5-23**] ulcerated 60%
RCA lesion x 3 BMS here, s/p LAD stents on [**2186-6-6**] at [**Hospital1 112**]
- PACING/ICD: temporary pacing wire [**5-22**] for transient CHB
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
h/o CVA, no residual deficit
GERD
h/o parathyroid adenoma s/p removal
Social History:
She does not currently smoke. No alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=...BP= 129/81 HR= 90 RR= 16 O2 sat= 97% 2L NC
GENERAL: Elderly female with increased psychomotor activity,
difficulty lying still
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. S3 heard throughout
precordium. No S4.
LUNGS: No chest wall deformities noted. Resp were unlabored, no
accessory muscle use. Poor inspiratory effort but CTAB without
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e, slightly cool feet and hands with good
cap refill
SKIN: Small skin tear over R lower shin.
PULSES: R and L DPs dopplerable, 1+ PTs
.
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
[**2190-10-17**] 05:45AM BLOOD WBC-13.7* RBC-2.99* Hgb-9.4* Hct-26.2*
MCV-88 MCH-31.4 MCHC-35.8* RDW-13.3 Plt Ct-230
[**2190-10-17**] 05:45AM BLOOD Neuts-83.5* Lymphs-12.4* Monos-3.2
Eos-0.8 Baso-0.2
[**2190-10-17**] 09:30AM BLOOD PT-15.3* PTT-76.2* INR(PT)-1.3*
[**2190-10-17**] 05:45AM BLOOD Glucose-184* UreaN-14 Creat-0.7 Na-135
K-4.0 Cl-101 HCO3-22 AnGap-16
[**2190-10-17**] 09:30AM BLOOD ALT-39 AST-63* CK(CPK)-356* AlkPhos-328*
TotBili-0.4
[**2190-10-17**] 05:45AM BLOOD cTropnT-0.18*
[**2190-10-17**] 09:30AM BLOOD Albumin-3.6 Calcium-8.2* Phos-3.1 Mg-2.0
[**2190-10-17**] 09:30AM BLOOD %HbA1c-7.3* eAG-163*
[**2190-10-17**] 10:40AM BLOOD Lactate-0.9
.
DISCHARGE LABS
.
MICROBIOLOGY
[**2190-10-18**] Urine culture (final): No Growth
[**2190-10-19**] Urine culture (final): No Growth
[**2190-10-19**] Blood culture: NGTD
.
IMAGING
[**2190-10-17**] CARDIAC CATHETERIZATION:
1. Selective coronary angiography of this right dominant system
revealed single vessel coronary artery disease. The LMCA had no
angiographically apparent disease. The LAD had mild luminal
irregularities and a patent stent. The LCx had mild luminal
irregularities. The RCA was found to be totally occluded very
proximally/ostially.
2. Limited resting hemodynamics revealed severe hypotension with
initial
blood pressure of 73/50 and bradycardia with heart rate of
40bpm. She
was receiving Levophed and Dopamine from the ED. An urgent
temporary
pacing wire was placed and set with rate of 80bpm with
successful
capture.
3. Successful PCI and stenting of a mid-RCA 100% occlusive
culprit
lesion with a 3.0 x 12 mm Integrity bare metal stent with no
residual
stenosis. Minimal residual stenosis in the distal RCA stent and
in the
RPL branch following POBA (to ensure adequate outflow from the
mid-RCA
stent).
FINAL DIAGNOSIS:
1. STEMI due to stent thrombosis of the proximal RCA bare metal
stent
placed in [**2186**].
2. Successful placement of temporary pacer wire for bradycardia
associated with hemodynamic compromise.
3. Initial hemodynamic compromise improved with pacing,
pressors, and
revascularization. Patient was able to be weaning off pressors
by end of
case with hemodynamic stability.
4. Aspirin 325mg daily x3 months then 162mg daily x12 months.
[**Year (4 digits) **]
75mg daily for minimum 3 months, likely longer.
.
[**2190-10-17**] ECG: Sinus rhythm. A-V conduction delay. There are ST
segment elevations in leads II, III and aVF with corresponding T
wave inversions, as well as T wave inversions in leads V5-V6
consistent with acute transmural ischemia in the inferolateral
territory. Compared to the previous tracing of [**2186-5-25**] inferior
injury pattern is new. Clinical correlation is suggested.
.
[**2190-10-18**] ECG: Sinus rhythm. Deep T wave inversions in leads II,
III and aVF. T wave flattening in leads V5-V6. Compared to the
previous tracing of [**2190-10-17**] ST segment elevations have resolved.
However, T wave inversions are deeper consistent with evolution
of acute myocardial infarction.
.
[**2190-10-17**] ECHO
LV systolic function appears depressed (ejection fraction 40
percent) secondary to severe hypokinesis of the inferior and
posterior walls. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. Aortic stenosis is present (not quantified). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**1-17**]+) mitral regurgitation is
seen (may be underestimated due to technically suboptimal
imaging). There is no pericardial effusion.
.
[**2190-10-18**] ECHO
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild to moderate regional left
ventricular systolic dysfunction with hypokinesis of the basal
half of the inferior and mid inferolateral walls. The remaining
segments contract normally (LVEF = 50%). 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. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve appears structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**1-17**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (PDA distribution). Mild-moderate
mitral regurgitation. Mild aortic valve stenosis. Pulmonary
artery hypertension.
Compared with the prior study (images reviewed) of [**2190-10-17**],
global left ventricular systolic function is minimally improved.
.
[**2190-10-18**] CHEST (PORTABLE AP): There is a new inferior approach
pacing lead with its tip in the region of the right ventricle.
There is unchanged dense calcification of the aortic arch and
the descending aorta. There are low lung volumes with small
bilateral pleural effusions and retrocardiac and left basilar
atelectasis. There is marked prominence of the pulmonary
vasculature. No pneumothorax is present. The heart is top normal
in size.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **]yo F with history of inferolateral STEMI in
[**5-22**] who presents with inferior STEMI from RCA stent thrombosis
complicated by bradycardia, s/p BMS placement to the mid-RCA.
.
.
ACTIVE ISSUES
# Inferior STEMI: Patient has a history of prior RCA STEMI in
[**2186**] with 3 BMS and presented with thrombosis of the stents now
causing STEMI. This was ballooned open with improvement in her
hemodynamics. There was successful PCI and stenting of a mid-RCA
100% occlusive culprit lesion with a 3.0 x 12 mm Integrity bare
metal stent with no residual stenosis. She was [**Year (4 digits) 4532**] loaded
and will continue on Integrillin for the next 18 hours. Her
HbA1C was 7.3 and TTE showed mild to moderate regional left
ventricular systolic dysfunction (EF= 50%) with hypokinesis of
the basal half of the inferior and mid inferolateral walls. She
was continued on [**Last Name (LF) 4532**], [**First Name3 (LF) **], valsartan, metoprolol, and
switched to atorvastatin from simvastatin.
.
# RHYTHM: She was bradycardic to the 30s likely from increased
vagal tone during STEMI and hypotensive in the ED. Temporary
pacer was inserted in the cath [**First Name3 (LF) **] and left in for monitoring.
Her native rate improved after intervention and the pacer was
pulled, but she was given small dose beta blocker (25mg Toprol
XL) to avoid withdrawal.
.
# Esophageal pain: Pt reported pain in her esophagus and
epigastrum, especially when eating. She was given GI cocktail
along with famotidine. Etiology of the pain is unclear. She had
no evidence of [**Female First Name (un) **] in her oropharynx. GERD is a possibility
though it is likely she would have improved with famotidine.
Pill esophagitis is a possibility. Eventually the pain subsided.
Would recommend outpatient GI follow-up if symptoms continue.
.
.
CHRONIC ISSUES
# CHF: No echo in our system but suspect she has component of
ischemic cardiomyopathy given her history and daily use of
lasix. No current signs of failure on exam and had transient S3
on physical exam. TTE showed moderate regional left ventricular
systolic dysfunction with hypokinesis of the basal half of the
inferior and mid inferolateral walls. LVEF = 50% with pulmonary
artery hypertension. She had some crackles bilat on day of
discharge and her lasix was increased to 20 mg daily from 10 mg
daily. She was advised to check her weight daily and to stop the
increased dose if she has signs of dehydration.
.
# Shoulder pain: Patient continued to have bilateral shoulder
pain secondary to previous rotator cuff injuries. She will
continue to have home physical therapy for this pain.
.
# HTN: Once BP (and HR) tolerated it, she was continued on her
beta-blocker amlodipine. She was from her home [**Last Name (un) **] to valsartan
while in-house.
.
# HLD: Her calculated LDL was 87 on [**10-4**]. She was switched to
80mg atorvastatin from simvastatin to achieve goal <70.
.
# GERD: She was switched from omeprazole to famotidine given
[**Month/Year (2) 4532**] use.
.
# Hypothyroidism: She was continued on home Levoxyl.
.
.
TRANSITION ISSUES
1. Perform full anemia work-up as an outpatient, including iron
studies, B12 and folate.
2. VNA to send labs on Tuesday to check electrolytes on new
medicines.
Medications on Admission:
AMLODIPINE [NORVASC] 5 mg daily
BUPROPION HCL 75 mg daily
FUROSEMIDE 10mg daily
IRBESARTAN [AVAPRO] 300 mg daily
ISOSORBIDE 30 mg daily
METOPROLOL SUCCINATE 50 mg qAM, 25mg qHS
POTASSIUM CHLORIDE 15 mEq daily
ASPIRIN 325 mg daily
OMEPRAZOLE 20 mg daily
Levoxyl 50 mcg daily
Simvastatin 80mg daily
Ocuvite
MVI
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): take 2 tablets on [**2190-10-22**].
Disp:*30 Tablet(s)* Refills:*11*
5. irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. potassium chloride 15 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
9. Outpatient [**Date Range **] Work
Check Chem-7 on Monday [**2190-10-25**] with results to Dr. [**Last Name (STitle) 1968**] at
[**Telephone/Fax (1) 3329**]
10. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. potassium & sodium phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO BID (2 times a day) for
3 doses.
Disp:*3 Powder in Packet(s)* Refills:*0*
14. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ST elevation myocardial infarction
Hypertension
Gastro-esophageal reflux disease
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 had a small heart attack because there was a clot in the
stent that blocked blood flow to your heart. The clot was
removed and you had another bare metal stent placed in the right
coronary artery. You will be on a full dose aspirin and
clopidogrel for the next few months and possibly longer. It is
extremely important that you take the aspirin and clopidogrel
every day without fail to keep the stent from clotting off again
and causing another heart attack. Do not stop taking aspirin or
clopidogrel unless Dr. [**Last Name (STitle) **] tells you it is OK. Your heart rate
was low during your heart attack and you needed a temporary
pacer to help your heart beat. Your heart rate is now normal.
Your echocardiogram showed good heart function and should
improve in the next moonth. You had some stomach upset that we
think is not related to your heart. You were started on some
medicines to help and can stop taking the medicines if you
stomach feels better. Weigh yourself every morning, call Dr.
[**Last Name (STitle) **] if weight increases more than 3 pounds in 1 day or 5
pounds in 3 days.
.
While you were here, you were found to be anemic with low blood
count. This should be evaluated further by your primary care
physician.
.
We made the following changes to your medicines:
1. Take clopidogrel ([**Last Name (STitle) **]) 2 doses on [**10-23**], then one pill
every day thereafter. Take with 325 mg of aspirin to prevent the
stent from clotting off again.
2. Decrease metoprolol to 50 mg daily to lower your heart rate
3. Increase furosemide to 20 mg daily to get rid of extra fluid
4. STOP taking omeprazole, start famotidine twice daily instead
to treat your heartburn.
5. START neutrophos for 3 doses to treat your low phosphate
level
6. STOP taking simvastatin, take Atorvastatin instead to lower
your cholesterol.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: TUESDAY [**2190-11-2**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10604**], MD [**Telephone/Fax (1) 3329**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 72614**], MD
Specialty: Cardiology
Location: LOWN CARDIOVASCULAR GROUP
Address: [**Hospital1 72615**], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 34506**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] for
within 1 month of your discharge from the hospital. You will be
called at home with the appointment. If you have not heard
within 2 business days, please call the number above.
|
[
"458.8",
"428.32",
"458.29",
"401.9",
"530.81",
"414.8",
"V12.54",
"466.0",
"410.41",
"E879.0",
"996.72",
"244.9",
"428.0",
"272.4",
"719.41",
"414.01",
"427.89",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"00.45",
"37.78",
"37.22",
"36.06",
"00.66",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
14104, 14162
|
8646, 11931
|
259, 315
|
14287, 14287
|
3336, 5136
|
16330, 17190
|
2411, 2493
|
12291, 14081
|
14183, 14266
|
11957, 12268
|
5153, 8623
|
14470, 16307
|
2508, 3317
|
1998, 2213
|
214, 221
|
343, 1918
|
14302, 14446
|
2244, 2330
|
1940, 1978
|
2346, 2395
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,997
| 193,257
|
31954
|
Discharge summary
|
report
|
Admission Date: [**2177-10-2**] Discharge Date: [**2177-10-14**]
Date of Birth: [**2105-8-12**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
chronic ischemic left #2 toe ulceration
Major Surgical or Invasive Procedure:
left fem-poop bpg with vein and left #2 toe amp [**2177-10-9**]
History of Present Illness:
72y/o referd for evaluation of ischemic left second toe with
chronic ulceration
and toe amputation.
Past Medical History:
histroy of PVD,s/p rt. BKa
histroy of DM2 with neuropathy
histroy of chronic diastolic CHF, compensated
histroy of hypertension
histroy of DJD s/p rt. TKR
histroy of total abdominal hystrectomy
Social History:
lives with daughter
former tobacco use d/c'd x 1 yr
denies ETOH use
Family History:
unknown
Physical Exam:
Vital signs:97.7-66-16 132/60 O2 sat 92% 2l/nc
gen: Ox3
heart: RRR
lungs: clear to Ausculation
Abd: bengin
EXT: smal left second to ulcer with purulence but minimul
erythema,s/p rt. BKA
pulse exam: femoral diffcult tossesss, palpable rt. [**Doctor Last Name **]. absent
left [**Doctor Last Name **] dopperable left pedal pulses
Neuro: nonfocal
Pertinent Results:
[**2177-10-2**] 10:33PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2177-10-2**] 10:33PM URINE BLOOD-SM NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2177-10-2**] 10:33PM URINE RBC-[**2-17**]* WBC-[**5-25**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
Brief Hospital Course:
[**2177-10-2**] admitted. Iv hydrated with NaHCO3 gtt and mucomyst for
anticipated angiogram. antibiotics of vanco,cipro and flagyl
began.
[**2177-10-3**] arterial studies showed significant sfa and tibial
disease on left.[**Last Name (un) **] consulted for DM managment. cardology
consulted for managment of CHF and periop cardiac risk
assesment.Patient described symptoms of exertional angia.
recommedn ETT and EcHO. anticipated angio cancelled.
[**2177-10-4**] stable
[**2177-10-6**] angio and stress test planned.continued insulin
adjustment for elevated fasting glucoses.pateint tolerated
angio.Stress defered until [**10-7**]
[**2177-10-7**] Stress negative for ischemic changes. Echo not optimal
but EF 50% with moderate diastolic sysfunction.
[**2177-10-8**] prepared for elective vascular surgery [**10-9**]
On [**10-9**] she was brought to the OR for a L fem to [**Doctor Last Name **] bypass and
a 2nd toe amputation. Postoperatively she was extubated but
required reintubation for respiratory distress. She remained
intubated and was diuresed in the recovery room. She was
extubated in the PACU and transferred to the ICU. On [**10-11**] she
was transferred to the vascular ICU in stable condition. Her
diet was advanced and her catheter was removed. On [**10-13**] she
was transferred to the floor and she was seen by physical
therapy. She was discharged to rehab on [**10-14**] in stable
condition, tolerating POs, voiding, and with her pain
controlled.
Medications on Admission:
[**Last Name (un) 1724**]: NPH 48/22, metop 12.5", lasix 40', remeron, reglan, lipitor
40', percocet, xanax, zoloft, methacarbamol, ASA 81'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
10. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1)
Intramuscular Q4H (every 4 hours) as needed for anxiety.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
14. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed.
19. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 10
breakfast, 7 Bedtime Subcutaneous see above.
20. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Sliding
scale Subcutaneous after meals: resume home sliding scale of
insulin.
21. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for SOB.
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
23. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four
times a day: QIDHCS.
24. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Country [**Hospital 731**] Rehabilitation & Nursing Center - [**Location (un) 5028**]
Discharge Diagnosis:
ischemic left#2 toe ulcer, chronic
histroy of DM2 with neuropathy
histroy of hypertension
histroy of perpheral vascular disease s/p right BKA
histroy of hypercholestremia
histroy of chronic diastolic CHF,compensated
histroy of DJD s/p TKR rt.
history of total abdominal hystrectomy
history of MRSA
Discharge Condition:
stable
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-18**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
2 weeks, Dr. [**Last Name (STitle) 1391**]. call for an appointment [**Telephone/Fax (1) 1393**]
|
[
"585.4",
"707.03",
"428.32",
"707.15",
"250.60",
"518.5",
"V49.75",
"682.6",
"403.90",
"428.0",
"V43.65",
"E878.2",
"357.2",
"440.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"84.11",
"96.71",
"39.29",
"88.42",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
5294, 5406
|
1553, 3028
|
312, 378
|
5748, 5757
|
1213, 1530
|
8499, 8599
|
825, 834
|
3218, 5271
|
5427, 5727
|
3054, 3195
|
5781, 8067
|
8093, 8476
|
849, 1194
|
233, 274
|
406, 507
|
529, 724
|
740, 809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,447
| 154,052
|
32057
|
Discharge summary
|
report
|
Admission Date: [**2145-5-19**] Discharge Date: [**2145-5-23**]
Date of Birth: [**2108-6-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Betadine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Non-specific malaise
Major Surgical or Invasive Procedure:
[**2145-5-19**] Mitral valve repair
History of Present Illness:
Mr. [**Known lastname 75060**] is a very nice 36-year-old man with known mitral
valve prolapse for approximately the last four years. He was
always told he had a heart murmur since childhood but was not
diagnosed with mitral valve prolapse until [**2141**] when he was
worked-up for dizziness. More recently he developed a febrile
illness following in [**2145-1-23**] which consisted of a few weeks
of fever, sweats and cough. He had significantly exerted himself
for several hours shoveling snow and came ill a day or two
later. He was ultimately diagnosed with pneumonia and placed on
antibiotics. Around the same time, he had obtained a new primary
care physician and given his history of mitral valve prolapse,
an echocardiogram had been electively scheduled for further
follow-up. This revealed a newly-flail posterior mitral leaflet
with severe regurgitation, a dilated left ventricle and
pulmonary hypertension. As this was found in conjunction with
his febrile illness and he had his teeth cleaned several weeks
prior, there was a concern for endocarditis however work-up was
negative. Currently he admits to fatigue and overall not feeling
well the last few months. He does not have any chest discomfort,
palpitations, orthopnea or exertional dyspnea. Due to
echocardiographic evidence of early LV decompensation with
dilation, he has been referred for cardiac surgery and was first
evaluated [**4-2**].
Past Medical History:
- Mitral Valve Prolapse with Mitral Regurgitation
- Secondary pulmonary hypertension by echo
- Hypertension
- Mild chronic thrombocytopenia
- Status post surgery for herniated lumbar disc age 19
Social History:
Race: Caucasian
Last Dental Exam: Late [**Month (only) 1096**]/Early [**2145-1-23**] - No
Prophylaxis
Lives with: Wife who is a physician
[**Name Initial (PRE) 75061**]: Real estate attorney
Tobacco: Denies
ETOH: Social use. Few glasses wine/week
Family History:
Father MI in his mid/ate 50's. Mom with [**Name2 (NI) **].
Physical Exam:
Pulse: 73 99% sat
R 120/76 L 130/75
Height: 72" Weight: 235
General: WDWN in NAD
Skin: Warm, dry and intact. No lesions or rashes. Small incision
well healed on lower back.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-Obscured S2, IV/VI holosystolic murmur.
Cardiac
PMI is displaced laterally.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X];no HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Superficial spider varicosities noted.
Neuro: Grossly intact; MAE [**5-27**] strengths, nonfocal exam
Pulses:
Femoral Right:1+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right: Transmitted Left: None
Pertinent Results:
[**5-19**] Echo: Prebypass: The left atrium is dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No spontaneous echo contrast is seen in the
body of the right atrium. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses are normal.
The left ventricular cavity is severely dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%). [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 stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened with more severe thickening of the posterior leaflet
with flail of the P2 and P3 scallops. An eccentric, anteriorly
directed jet of severe (4+) mitral regurgitation is seen. Due to
the eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). There is no
pericardial effusion.
Postbypass: The patient is in sinus rhythm and on an infusion of
norepinephrine. There is an annuloplasty ring in the mitral
position which appears well-seated. Mitral regurgitation is now
trace. Mean gradient is 3 mmHg at a CO of 6.4 L/min.
Biventricular systolic function is preserved. Other valvular
findings are unchanged. The thoracic aorta is intact post
decannulation.
Dr. [**Last Name (STitle) **] was notified in person of the results at the time of
the study.
[**2145-5-23**] 06:10AM BLOOD WBC-8.5 RBC-3.91* Hgb-10.9* Hct-32.2*
MCV-82 MCH-27.8 MCHC-33.9 RDW-12.9 Plt Ct-124*
[**2145-5-23**] 06:10AM BLOOD Plt Ct-124*
[**2145-5-23**] 06:10AM BLOOD UreaN-11 Creat-0.7 Na-136 K-4.3 Cl-100
[**2145-5-23**] 06:10AM BLOOD Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 75060**] was a same day admission and was brought directly to
the operating room where he underwent a mitral valve repair.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later that day he was weaned from pressors.
He awoke neurologically intact and extubated. His chest tubes
were removed and he was transferred to the surgical step down
floor. he developed post operative afib on POD#3 which lasted
approx 12 hrs and converted to SR w/ IV amiodarone. Couamdin was
not started. His platelet count was low (77) but he has a
history of thrombocytopenia. HIT was negative. He was started on
betablockade and diuresed toward his pre-operative weight. He
was evaluated by physical therpay for strength and conditioning
and was discharged to home on POD#4. All instructions were
advised and appointments made.
Medications on Admission:
Amoxicillin prn dental
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
400mg twice daily for 5 days then 400mg daily for 7 days then
200mg ongoing until your are instructed to stop.
Disp:*120 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral valve prolapse/regurgitation s/p Mitral valve repair
Past medical history:
Secondary pulmonary hypertension by echo
- Hypertension
- Mild chronic thrombocytopenia
- Status post surgery for herniated lumbar disc age 19
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema- trace
Discharge Instructions:
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) **] on [**2145-6-10**] at 1;30pm [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 171**] on [**2145-6-28**] 9:20am [**Telephone/Fax (1) 62**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 1968**] in [**4-27**] 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:[**2145-5-23**]
|
[
"E878.8",
"401.9",
"285.1",
"428.0",
"287.5",
"416.8",
"424.0",
"451.84",
"427.31",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7329, 7387
|
5159, 6085
|
296, 334
|
7656, 7818
|
3254, 5136
|
8659, 9215
|
2274, 2334
|
6158, 7306
|
7408, 7469
|
6111, 6135
|
7842, 8636
|
2349, 3235
|
236, 258
|
362, 1776
|
7491, 7635
|
2010, 2258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,423
| 197,821
|
51434
|
Discharge summary
|
report
|
Admission Date: [**2110-2-6**] Discharge Date: [**2110-2-8**]
Service: MEDICINE
Allergies:
Opioid Analgesics
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83yo man with complicated medical history including CAD s/p
CABG, Afib, CVA, systolic CHF (LVEF 25% by TTE [**7-7**]), DM2 with
peripheral neuropathy, PVD with R fem-[**Doctor Last Name **] bypass, upper GI
bleed, anemia felt to be of chronic disease, who presents from
rehab with diarrhea, lethargy, and persistent hypoglycemia in
the setting of sulfonylureas. The patient was in USOH, other
than some loose stools over the past week or so, when he noted
acute onset weakness and fatigue after finishing breakfast. He
denied CP, N/V, SOB, palp, diaphor, or LH. The symptoms
persisted until he came to the ED, afterwards, he reports they
resolved, and he felt fine upon arrival to the ICU. ROS
otherwise negative for cough, SOB, DOE, CP, abd pain, dysuria,
orthopnea, PND. He notes that the LE edema is stable since he
saw Dr. [**Last Name (STitle) **] (PCP) a few weeks ago, and that his weight this AM
was 204 lbs, which is about where it's been lately. He was
given all of his meds at rehab. Per EMS report, his FS glucose
was as low as 36, and he was given 2 1mg glucagon, and PO
glucose, with improvement to 62. He was sent to the ED, where
his initial glucose was 50.
*
In the ED, he was given multiple injections of D50, with little
improvement in FS. He was then started on octreotide gtt for
treatment of presumed medication (sulfonylurea) induced
hypoglycemia. He was given Vanco 1g, then seen by vascular for
evaluation of his foot and recommended holding antibiotics. He
was admitted to the ICU due to frequent fingerstick requirement
for the hypoglycemia. FS in the ED were 74 up to 222 prior to
leaving for the floor. He was trace guaiac positive in ED, with
brown stool.
*
Previous hospitalization (from Dr. [**Last Name (STitle) 88368**] note [**2110-1-27**]):
Pt p/t [**Hospital1 18**] ER on [**2109-12-18**] with "feeling lousy," weak and mildly
SOB, was found to have anemia lower than baseline (hct 25) and
some mild CHF, guaiac negative. He had a CTA done to r/o PE,
which it did, though it noted a RUL nodule and apical scarring
concerning for TB. He was put in isolation and had 3 sputums
negative for AFB on smear, cultures still pending today [not
available in OMR]. PPD was negative as well. He had a X-ray and
then MRI of his R foot to investigate a non-healing ulcer, and
was found to have osteomyelitis for which he underwent a R TMA.
He had ARF in setting of contrast dye for CTA, which resolved
over his hospital stay (back to bl 1.2-1.3). He also had low plt
counts, with a Hematology consult suggesting was from his
carvedilol, which was stopped and changed to metoprolol. He had
a HIT Ab sent that was positive, though the subsequent serotonin
release assay (gold standard) was normal, meaning he likely does
not have HIT. His plt count improved from 100k to 153k prior to
discharge. His anemia was felt [**1-3**] chronic inflammation, as his
B12, folate and iron studies were unrevealing. His blood sugars
were running low, so his glimepiride was decreased to 2mg [**Hospital1 **].
*
When seen by Dr. [**Last Name (STitle) **] on [**2110-1-27**], he was noted to be 20 lbs
above his 'dry weight' of 195 lbs. He was restarted on lasix
40mg, with plans to have follow up labs drawn in 1 week.
Anticoagulation was again addressed for his afib, which the
patient declined given his difficulty with GI bleeding, as well
as difficulty following his INR. His Fe supplements were
stopped, as he was not found to have iron deficiency anemia at
the time (Ferritin > 700).
Past Medical History:
1. Coronary artery disease status post CABG in [**2090**]; no history
of angina
2. CHF with LVEF 25% on transthoracic echo done [**2109-7-4**].
3. Peripheral vascular disease followed by Dr. [**Last Name (STitle) 1391**], status
post right femoral bypass graft; R TMA last admission
4. Atrial fibrillation, not on anticoagulation secondary to GI
bleed.
5. Hyperlipidemia.
6. Type 2 diabetes with complications of neuropathy and likely
nephropathy, unclear if he had retinopathy.
8. MSSA bacteremia recently thought to be from right foot ulcer.
9. Peptic ulcer disease.
10. Umbilical hernia status post repair.
11. Status post gallbladder removal.
12. History of CVA with mild left-sided residual weakness.
13. Healthcare maintenance: Last colonoscopy in [**2104**] was
reportedly normal, done at the VA.
14. HIT Ab+, Serotonin release assay negative
Social History:
Lives with his wife at home who is the primary caretaker for
him. Tobacco use, approximately 10 pack years, quit 50 years
ago. No alcohol or drug use reported.
Family History:
Non-contributory
Physical Exam:
*
Vitals: T 96.0
BP 110/51
HR 87
R 14
Sat 99% 2L NC
*
PE: G: Elderly male, NAD, WN, WD
HEENT: Clear OP, MMM, dentures
Neck: Supple, No LAD, JVD up to ear lying in bed, No carotid
bruit
Lungs: BS BL, Diffuse expiratory wheezes, no R/C
Cardiac: NL rate. Distant S1S2. No murmurs appreciated
Abd: Soft, NT, ND. NL BS. No HSM.
Ext: [**1-4**]+ pitting edema. R foot amputation site--C/D/I, no
increased warmth or erythema
Neuro: A&Ox3. Appropriate. Grossly normal
Pertinent Results:
IMAGING:
R Foot films: Further metatarsal resections since the prior
study as described above. No overtly concerning findings for
osteomyelitis, although no localizing history was provided
regarding the area of erythema.
*
CXR: 1. Mild pulmonary edema. 2. Minimal air space opacities
in the left costophrenic angle, a nonspecific finding.
*
EKG: Afib at 81. Borderline LBBB with 1 VPC. NL axis. Diffuse
nonspecific TW flattening, no ST deviations. Compared with prior
[**2110-1-2**], no appreciable change.
*
ADMISSION LABS:
GLUCOSE-51* UREA N-52* CREAT-1.5* SODIUM-133 POTASSIUM-3.1*
CHLORIDE-99 TOTAL CO2-19* ANION GAP-18
WBC-8.4 RBC-2.68* HGB-8.2* HCT-24.1* MCV-90 MCH-30.8 MCHC-34.2
RDW-15.8*
CK(CPK)-121 CK-MB-4 cTropnT-0.08*
Brief Hospital Course:
Mr. [**Known lastname 1662**] is an 83-year-old man with a history of CAD s/p CABG,
DM, Atrial fib, CHF (EF 25%) and PVD s/p right transmetatarsal
amputation who presented with fatigue and lethargy and was found
to be hypoglycemic. His brief hospital course by problem is as
follows:
.
1. Hypoglycemia. This was attributed to a sulfonylurea effect in
the setting of poor clearance from renal impairment. This
resolved with octreotide and dextrose. He was admitted to the
ICU given the need for frequent fingersticks, but he did not
have any hypoglycemic symptoms after his admission and his
sugars remained fairly well controlled. His glimepiride was held
while he was an inpatient and he was covered with a regular
insulin sliding scale. On discharge, he was instructed to take a
lower dose (1 mg [**Hospital1 **] instead of 2 mg qam and 1 mg qpm); this may
need to be adjusted back up since his renal function is
improved.
.
2. Fatigue. This was most likely due to his hypoglycemia.
Cardiac enzymes ruled out an MI; a small leak was consistent
with his renal failure and the enzymes went down from there.
.
3. Acute Renal Failure. This was attributed to being pre-renal
in the setting of diarrhea combined with ongoing Lasix use. His
Lasix was held while he was admitted and restarted at half his
usual outpatient dose at the time of discharge. His ACE
inhibitor was also held. *** This should be resumed as an
outpatient. *** His creatinine returned to near his baseline by
discharge.
.
4. Positive blood culture. He had 1/4 bottles from his admission
cultures grow Gram-positive cocci; speciation was pending at the
time of discharge. As he was afebrile without a leukocytosis, it
was believed that this was a contaminant. Nonetheless, if he
should develop a fever, he should be recultured and covered with
antibiotics.
.
5. CHF. He did not appear to be in overt failure, although he
did have an elevated JVP and some crackles in his lungs. As
above, his Lasix and lisinopril were held due to his kidney
function and should be readjusted as an outpatient. He was
continued on a beta blocker.
.
6. Cardiac rhythm. He had several runs of Non-sustained V Tach
the day after admission. This resolved with electrolyte
repletion and an increased dose of his metoprolol; he was
discharged with this increased dose.
.
7. Anemia. He has a known history of anemia of chronic disease.
He was reportedly Guaiac positive in the ED, but had no history
of BRBPR or black or melanic stools. His hematocrit remained
stable. An outpatient GI work-up may be considered.
.
8. PVD s/p R TMA. Vascular surgery evaluated him in the ED, and
they felt this was not likely to be acute infection.
.
9. FEN: He was given a Low Na/Cardiac/DM diet.
.
10. He was given prophylaxis with a PPI and Pneumoboots.
.
11. CODE: Full (verified)
.
12. DISPO: He was discharged back to [**Hospital 599**] Rehab, from where he
had been admitted.
Medications on Admission:
Folic Acid 1 mg PO DAILY
Hexavitamin 1 tab PO DAILY
Omeprazole daily
Glimepiride 2 mg PO QAM, 1mg QPM
Aspirin 325 mg PO DAILY
Ketoconazole 2 % Cream [**Hospital1 **] as needed: To groin
Hydrocortisone Valerate 0.2 % Cream [**Hospital1 **] as needed: To groin.
Lisinopril 5 mg PO DAILY
Metoprolol Tartrate 25 mg PO TID
Simvastatin 20 mg PO DAILY
Terazosin 2 mg PO Daily
Cyanocobalamin 1,000 mcg PO daily
Lasix 40mg PO BID (previously 20mg daily)
Spironolactone 25 mg PO DAILY
Ambien HS
Insulin SS (Not specified)
*
Allergies: Opioid Analgesics, ?Heparin Agents (HIT Ab+, SRA -)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: [**12-3**] INH Inhalation
Q6H (every 6 hours) as needed.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Unit
Injection ASDIR (AS DIRECTED): SLIDING SCALE: start at 2 units
at 151; increase by 2 units for every 50 points of glucose.
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
1. Hypoglycemia, medication-induced
2. Acute Renal Failure
.
Secondary:
1. Congestive Heart Failure, systolic
2. Anemia of Chronic Disease
3. Peripheral Vascular Disease
Discharge Condition:
Good condition, normoglycemic, vital signs stable, ambulatory.
Discharge Instructions:
You have been evaluated for hypoglycemia. It is likely that your
kidney function was slightly altered by some dehydration due to
your diarrhea. Therefore, the kidney could not clear out the
diabetes medication as effectively and your blood sugar became
too low. Your kidney function is now back to normal, but to be
safe, you are being discharged on a lower dose of your diabetes
medication. This may be increased back to its old level at a
later date. You are also being discharged on a lower dose of
your Lasix to protect your kidney; this too may be increased
later.
.
If you should experience any tremors, confusion,
lightheadedness, palpitations, chest pain, shortness of breath,
nausea/vomiting, further diarrhea, an inability to tolerate oral
intake, or any other symptom that is concerning to you, please
call your PCP or go to the nearest hospital emergency
department.
Followup Instructions:
Please f/u with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
by calling [**Telephone/Fax (1) 250**]. You should be seen within 1-2 weeks of
returning home. Ask them about your diabetes medication and your
Lasix dose.
.
In addition, you have the following appointments already
scheduled:
1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-3-10**]
10:00
2. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2110-3-10**] 11:00
3. Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2110-3-10**] 11:00
Completed by:[**2110-2-8**]
|
[
"443.9",
"427.1",
"250.40",
"250.60",
"V45.81",
"428.22",
"250.80",
"584.9",
"583.81",
"427.31",
"357.2",
"E932.3",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10979, 11051
|
6183, 9093
|
235, 241
|
11274, 11339
|
5425, 5937
|
12266, 13095
|
4851, 4869
|
9721, 10956
|
11072, 11253
|
9119, 9698
|
11363, 12243
|
4884, 5406
|
182, 197
|
269, 3782
|
5953, 6160
|
3804, 4657
|
4673, 4835
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,600
| 116,726
|
24684+57412
|
Discharge summary
|
report+addendum
|
Admission Date: [**2104-9-29**] Discharge Date: [**2104-10-15**]
Date of Birth: [**2027-7-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2104-10-2**] Mitral Valve Replacement utilizing a [**Street Address(2) 11599**]. [**Male First Name (un) 923**]
mechanical valve and Two vessel coronary artery bypass grafting
with left internal mammary artery to left anterior descending,
and vein graft to obtuse marginal
History of Present Illness:
This is a 77 year old female who presented to outside hospital
with congestive heart failure. Her major complaints at that time
were shortness of breath and increasing fatigue. Cardiac
catheterization on [**9-25**] revealed severe three vessel
coronary disease, 3+ mitral regurgitation and an LVEF of 55%.
Angiography showed a non-dominant RCA with a 70% stenosis; 50%
ostial left main lesion; 95% stenosis in the LAD with diffuse
disease of the circumflex system. Based on the above results,
she was transferred to [**Hospital1 18**] for cardiac surgical intervention.
Of note, prior ECHO from [**2104-8-14**] was notable for severe
MR with an estimated LVEF of 40-45%.
Past Medical History:
Congestive Heart Failure
Mitral Regurgitation
Coronary Artery Disease
End-Stage Renal Disease
Atiral Fibrillation
Hypertension
Diabetes mellitus
Hyperlipidemia
Anxiety
Spinal stenosis
s/p right nephrectomy
s/p colostomy with reversal
s/p chole
s/p Totoal Abdominal Hysterectomy and Bilateral
salpingo-oophorectomy
Prior left leg vein stripping
Social History:
Occasional ETOH. No tobacco history.
Family History:
Non-contributory
Physical Exam:
VS: 100.0 105/52 80 20 99%2L 63.8kg
General: Pleasant elderly male in NAD
HEENT: PERRL, EOMI
Lungs: CTAB
Heart: SEM [**1-20**]
Abd: Soft, NT/ND +BS
Ext: Cool feet w/ DP 1+ Bilat, -edema, +varicosities
Neuro: CN2-12 intact grossly
Pertinent Results:
[**2104-9-29**] 09:50PM BLOOD WBC-10.3 RBC-3.13* Hgb-10.7* Hct-31.4*
MCV-100* MCH-34.1* MCHC-34.0 RDW-15.1 Plt Ct-208
[**2104-10-4**] 03:14AM BLOOD WBC-22.2* RBC-3.14* Hgb-10.1* Hct-28.8*
MCV-92 MCH-32.0 MCHC-34.9 RDW-18.1* Plt Ct-130*
[**2104-10-14**] 06:40AM BLOOD WBC-12.4* RBC-3.16* Hgb-10.8* Hct-32.9*
MCV-104* MCH-34.1* MCHC-32.8 RDW-22.4* Plt Ct-113*
[**2104-9-29**] 09:50PM BLOOD PT-13.4* INR(PT)-1.2
[**2104-10-13**] 09:57AM BLOOD PT-18.5* PTT-150 IS HIG INR(PT)-2.4
[**2104-9-29**] 09:50PM BLOOD Glucose-135* UreaN-27* Creat-5.9* Na-137
K-4.6 Cl-93* HCO3-30 AnGap-19
[**2104-10-12**] 08:00AM BLOOD Glucose-152* UreaN-31* Creat-4.1* Na-136
K-4.8 Cl-97 HCO3-26 AnGap-18
[**2104-10-11**] 07:52AM BLOOD Albumin-2.7* Calcium-8.4 Phos-4.9* Mg-2.0
UricAcd-7.5*
[**2104-10-1**] 12:12PM URINE Blood-LG Nitrite-POS Protein-30
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD
Brief Hospital Course:
As noted in the HPI, pt was transferred to [**Hospital1 18**] and admitted
for surgical intervention. Prior to surgery pt needed to have
complete work-up which included labs, Echo, Chest CT, LE vein
mapping. She also required a Renal (for HD) and Dental consult.
Following work-up and consults, pt consented to surgery and was
brought to the operating room on HD#4 where she underwent a
Mitral valve replacement (27mm St. [**Male First Name (un) 923**] mechanical valve) and
two vessel coronary artery bypass. Pt. tolerated the procedure
well with bypass time of 113 minutes and cross-clamp time of 94
minutes. Please see op note for surgical details. Pt. was
transferred to CSRU in stable condition on the following gtts:
Epinephrine, Neosynephrine, and Nitroglycerin. Pt. remained
intubated for several days and on POD #2 was weaned from
mechanical ventilation and sedation and extubated. Pt. remained
in the CSRU for an extended period of time (until POD #7) d/t
requiring Neo or Epi for hemodyamic support. She was started on
a Heparin gtt and remained on that for awhile until Coumadin was
initiated and her INR was at a therapeutic level (>2.5). She
also had complete heart block (asystolic underneath temp. pacer)
while in the CSRU and had a permanent pacemaker placed on POD#5.
Epicardial pacing wires removed on this day. Chest tubes were
removed per protocol. Renal saw pt again post-operatively and
followed pt for entire hospital stay. She was dialyzed mutlpile
times while in the unit (and also while on the floor). She had
an elevated WBC during post-op period (>20'000's) and had blood
cultures and RIJ cordis tip sent for cultures (all negative).
She also had 2 units of red cells transfused on POD #6 d/t low
Hct (26). Pt. was evaluated by Physical Therapy and worked with
pt during entire post-operative period. Once pt. was transferred
to telemetry floor, POD #7, she slowly improved and increased
ambulation. She had some pedal edema on exam at time of
discharge otherwise exam was unremarkable. Labs were stable (Hct
increased to 36.5 and WBC was down to 11.9) and she remained on
the floor until POD #12 when she was discharged to a rehab
facility
Medications on Admission:
1. Lisinopril 2.5mg qd
2. Nephrocaps 1mg qd
Zocor 10mg qhs
4. Nortriptyline 25mg qhs
5. Epogen [**2098**] IV qd
6. ASA 81mg qd
7. Hydroxyline 25mg qhs
8. Humalin sliding scale
9. Atenolol 25mg bis
10. Heparin gtt
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. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO ONCE (once): check
INR [**2104-10-16**] and PRN.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 62289**] hospital of [**Doctor Last Name **]
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Replacement([**Street Address(2) 11599**]. [**Male First Name (un) 923**]
mechanical valve)
Coronary Artery Disease s/p Two vessel coronary artery bypass
grafting(LIMA to LAD, vein graft to OM)
Congestive Heart Failure
End-Stage Renal Disease
Atiral Fibrillation
Hypertension
Diabetes mellitus
Hyperlipidemia
Anxiety
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. Avoid creams, lotions and
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-18**] weeks
Dr. [**Last Name (STitle) **] in [**1-17**] weeks
Completed by:[**2104-10-14**] Name: [**Known lastname 11197**],[**Known firstname 5210**] Unit No: [**Numeric Identifier 11198**]
Admission Date: [**2104-9-29**] Discharge Date: [**2104-10-15**]
Date of Birth: [**2027-7-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4551**]
Addendum:
Lopressor was dc'd at discharge, as it hadbeen held bynursing
for approximately 2 days secondart to systolic blood pressure in
the 90s to low 100s.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11199**] hospital of [**Doctor Last Name **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2104-10-14**]
|
[
"427.31",
"272.4",
"585.6",
"V58.67",
"V58.83",
"V58.61",
"300.00",
"443.9",
"250.40",
"403.91",
"396.3",
"285.9",
"398.91",
"426.0",
"414.01",
"V45.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"39.95",
"39.64",
"35.24",
"37.72",
"99.69",
"36.11",
"99.04",
"99.07",
"88.72",
"37.83",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7635, 7874
|
2955, 5126
|
342, 620
|
6718, 6724
|
2040, 2932
|
6938, 7612
|
1757, 1775
|
5389, 6214
|
6341, 6697
|
5152, 5366
|
6748, 6915
|
1790, 2021
|
283, 304
|
648, 1320
|
1342, 1687
|
1703, 1741
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,695
| 138,713
|
743
|
Discharge summary
|
report
|
Admission Date: [**2161-2-2**] Discharge Date: [**2161-2-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
hypotension, mental status changes, respiratory distress/failure
Major Surgical or Invasive Procedure:
R-sided Femoral line
R-PICC
Tracheostomy
Pleurex Catheter Placed-L sided
History of Present Illness:
[**Age over 90 **] yo M with hx of hypothyroidism, Afib, CAD, HTN, new diagnosis
of GE junction lymphoma (s/p 3 months of radiation therapy with
tumor size [**1-5**] as before but now no longer candidate for
radiation therapy) who presents from [**Hospital 100**] Rehab with call0in
with tachypnea, RR 40's with frequent suctioning of very thick
mucous.
.
Came from [**Hospital 100**] Rehab with complaints of SOB and DOE. He got
Morphine 8mg po x 1 at [**Hospital 100**] Rehab prior to transfer and
subsequently developed mental status changes. On arrival, he was
noted to have temp 101, BP 70/p, HR 120's, RR6, 99% on 100% NRB.
He was given IVF wide open, 2mg Narcan with ?positive response
([**Name8 (MD) **] RN taking care of him with response in BP to 130s). Then,
he was noted to have a poor gag reflex with RR 4 and thus was
intubated for airway protection (getting succinylcholine and
etomidate). He was then started on versed for sedation. Shortly
after starting his versed, his BP was noted to be 77/45 and thus
was started on PERIPHERAL levophed while attempts made to place
a central line. After 20 minutes, IV infiltrated in arm and he
was given phentolamine at the IV site. His BP was 67/42 and
finally a R. groin line was placed. He was then started on
dopamine via R. groin line and became tachycardic and was
questionably was in VT and shocked 200J x 3 (no strips) and
started on lidocaine and magnesium. Currently on levophed at
6mcg/min and lido at 2mg/min wiht BP 92/49.He was also given 4L
of NS and IV ceftriaxone, Vancomycin, Flagyl.
.
Per son, he states that his father had been coughing white,
yellow sputum for about a week but did not complain of SOB or
chest pain. He states his mental status however has been the
same over the past couple of weeks and his baseline activity -
does not walk. Speaks in full conversations but has lapses of
memory at times.
.
Transferred to MICU for further care for respiratory failure,
and hypotension.
Past Medical History:
Hypothyroidism, CAD s/p MI [**2142**], EF 45%, HTN, BPH, Depression,
High cholesterol, GE Junction lymphoma, peripheral T cell
lymphoma
Social History:
Moved from [**Country 532**] 10 years ago
former engineer
wife with alzheimer's disease
lives alone, walks with cane
No ETOH, tobacco
Family History:
No h/o CAD
Physical Exam:
VS - T 98.3, BP 107/53, HR 62, RR 17, sats 100% on RA, wt 75.8kg
Vent: AC, PEEP 8, Tv set 550/actual 618, RR set 12/actual 15,
FiO2 100%
I/O: 210 UOP since placing foley catheter
Gen: Sedated, intubated.
HEENT: Sclera anicteric. Pupils pinpoint, nonrxtive. ? lateral
nystagmus on opening of his eyes.
CV: RR, normal S1, S2. No m/r/g.
Lungs: Coarse rhonchi on L anteriorly, decreased BS at L base.
Clear on the right.
Abd: Soft, NTND. Quiet BS. J tube dressing c/d/i.
Ext: Fem line on R, dsg c/d/i. No ecchymosis. 2+ PT, radial
pulses bilaterally.
Skin: No rashes. Area of infiltration on L forearm erythematous,
edematous. Was circled in ED, has not spread outside the
boundary.
Neuro: Withdraws all four extremities to pain.
Pertinent Results:
Na 122, K 5.5, Cl 89, HCO3 24, BUN 29, Cr 0.7, Glu 127, Mg 1.5
CK 33, trop 0.10
WBC 11.7, Hct 28.3, Plt 157 (diff 89N, 1B, 1L, 9M)
PT 12.5, PTT 30.9, INR 1.1
Amylase 40, lipase 11, ALT 25, Alk Phos 145
Lactate 2.1
UA - 1.012, sm LE, neg nitrite, neg glu, neg ketone, [**3-8**] RBC,
[**11-23**] WBC, few bacteria, [**3-8**] epi
.
Brief Hospital Course:
A/P: [**Age over 90 **] yo M with hx of GE junction lymphoma (s/p radiation
therapy for palliation), afib, hypothyroidism who presents with
PNA and hypotension.
1. Hypotension - Likely secondary to medications given (morphine
initially then versed in the setting of intubation). Unlikely to
be secondary to septic shock given that he was not initially
hypotensive and only was hypotensive in the setting of lots of
morphine and then lots of versed. however, septic shock is
possible given large PNA and UTI. Doubt cardiac etiology for
hypotension. In MICU continued to be hypotensive requiring
pressors-levophed. Not thought to be septic shock micro data was
negative throughout his hospitalization. He was fluid
resusitated however remained on pressors until [**2-23**], he was
started on Hydrocort/fludrocort on [**2-21**] for adrenal
insufficiency. His BP remained stable off pressors and will
continue Hydrocort/fludrocort for a 7 day course which will end
on [**2-27**].
.
2. Mental status changes - Possibilities include infection with
PNA and UTI, new hyponatremia in the setting of free water in
his TFs (more likely to be the cause), medications including
lots of morphine. MICU Course, his mental status was difficult
to guage with him being intubated and sedated. Off sedation pt
seemed to improve with being able to follow commands with the
russian interpreter and per sons. head CT negative for masses or
bleeds; multiple lacunar infarcts present.
.
.
#. PNA with large effusion - likely cause of new tachypnea. MICU
course-pt was intubated for resp failure found to have large
malignant effusions. Had a pleurex cath placed which drained
>1L/day. Resp status improved. Pt was successfully extubated
[**2-17**] and remained stable and called out to floor. His pleurex
catheter fell out and re-accumulated his L-sided effusion. He
also completed a 7 day course of vanc/zosyn for nosocomial PNA.
On following day on the medicine floor he then developed
respiratory distress, he was transferred back to the MICU and
reintubated. On CTA found to have small R-sided pleural
effusions. He was started on hep gtt for PEs. On CTA also found
to have a deviated and narrowed trachea [**2-5**] metastatic lymphoma
surrounding trachea and compromising airway. Pt remained
intubated [**2-5**] airway protection. On [**2-21**] he had 2nd pleurex
cath placed and connected to suction with continual drainage. He
was also trached on [**2-21**] surgically without complications.
Pleurex cath remained to suction, respiratory status improved.
On [**2-24**] started Trial on Trach Collar, however pt tired and was
put back on Vent. No complications post trach or pluerex cath.
.
#. UTI - will also be treated with abx as above. f/u cultures.
Completed 7 day course of Abx. No further UTI throughout MICU
course.
.
#.Rhythm - hx of afib. Unclear if he really had VT. He more
likely had rapid afib with dopamine wiht underlying LBBB which
made it look like VT. Unclear as no strips. In MICU developed AF
w/RVR was started on dilt gtt with success. Pt converted to NSR.
however he went back into AF was initially put on BB without
success. He was then loaded with Amiodorone for 1 day but was
poorly rate controlled. He was switched to dilt drip which had
good effect and converted to NSR. He was switched to PO dilt and
remained in NSR throughout MICU course. CE remained neg x3.
.
6. Hyponatremia - unclear if from lots of free water from tube
feeds. ?hypovolemic hyponatremia. Got 4L NS in ED. Recheck Na
level now. In MICU hyponatremia not an issue.
.
7. Hyperkalemia - hemolyzed. Also received succinylcholine in
ED. No peaked T-waves on EKG. Throughout MICU course, no
hyperkalemia.
.
8. hypothyroidism - continued levothyroxine.
.
#. lymphoma of GE junction - Dr. [**Last Name (STitle) **],oncologist notified. has
been getting palliative chemo but is no longer candidate for
further radiation.Per oncologist and MICU team, multiple
conversations had with family informing them of pt's extremely
poor prognosis. Per Oncologist, pt has days to weeks left given
poor prognosis, metastatic lymphoma now encasing carotids/major
vessels in neck as well as affecting/deviating trachea. Family
[**Hospital 5439**] hospice/palliative care, however family refused
palliative care services on multiple occasion. Documentation in
chart.
.
#. Hypercalcemia: [**2-5**] lymphoma, Continuing IVF- received
pamidronate on [**2161-2-14**]
.
#. FEN- Per Nutrition consult TF per PEG at goal.
.
# Access-R PICC placed [**2-25**].
.
#. DNR/Intubatable.
.
#. Contact - son HCP [**Name (NI) **] [**Name (NI) 4640**] [**Telephone/Fax (2) 5440**]H,
[**Telephone/Fax (2) 5441**]CELL
.
# Dispo: Screened for Chronic [**Hospital 5442**] Rehab, bed available on [**2-25**].
Medications on Admission:
ASA
Levothyroxine 200mcg daily
peptobismol
tylenol
nexium
MSO4 4MG Q2HR PRN
duonebs
pantop
dilt 60mg qd
metop xl 25 daily
isocal hn tube feeds 75cc/hr w/200cc water q4hr
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days.
9. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig: One
(1) Recon Soln Injection Q6H (every 6 hours) for 2 days.
10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED) for 2 days.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
15. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED): continue hep gtt
until INR 2.0 while transition to coumadin.
16. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
17. Midazolam 1 mg/mL Solution Sig: One (1) Injection Q4H
(every 4 hours) as needed.
18. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed.
19. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift. PLS
HOLD HEP GTT at 4am on [**2-24**] FOR PICC Placement IN AM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
-GE Junction T Cell Lymphoma
-Metastatic Mediastinal T cell Lymphoma with extensive lymphoma
encasing Carotids and deviating Trachea
-Malignant Pleural effusions
-R sided small Pulmonary Embolisms
-Atrial Fibrilation
Discharge Condition:
Stable
Discharge Instructions:
Pls continue pleurex cath to suction, may cap when output less
than 200cc per day.
.
Trach Collar as tolerated.
.
Followup Instructions:
None
Completed by:[**2161-2-25**]
|
[
"311",
"244.9",
"276.7",
"E935.2",
"486",
"275.42",
"414.01",
"518.81",
"276.1",
"427.31",
"202.12",
"202.13",
"458.9",
"599.0",
"401.9",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"99.04",
"96.72",
"96.6",
"31.1",
"97.03",
"38.93",
"38.91",
"33.24",
"96.04",
"34.91",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
10811, 10896
|
3850, 8601
|
326, 401
|
11157, 11166
|
3496, 3827
|
11329, 11365
|
2723, 2735
|
8822, 10788
|
10917, 11136
|
8627, 8799
|
11190, 11306
|
2750, 3477
|
222, 288
|
429, 2395
|
2417, 2555
|
2571, 2707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,757
| 189,199
|
1258
|
Discharge summary
|
report
|
Admission Date: [**2135-7-16**] Discharge Date: [**2135-7-19**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85yo Male with h//o MDS, ITP, and colon CA s/p hemicolectomy in
[**4-12**] with subsequent complications requiring repeat surgeries.
Patient had been at rehab facility doing well until [**2135-7-15**] when
noted to have low-grade fever and lethargy. On [**2135-7-16**] noted to
have fever to 102 with increased malaise & lethargy. Pt's PICC
line removed & cultures sent. Pt became increasingly lethargic
with hypotension to SBP 60's. Pt given IVF bolus & sent to ED.
No cough, SOB, nausea/vomiting, abd pain, urinary symptoms, HA.
Past Medical History:
1. PERIPHERAL EDEMA
2. DYSPHAGIA
3. ITP4.
4. GBS like peripheral neuropathy
5. GASTROESOPHAGEAL REFLUX
6. NECK PAIN
7. CHRONIC CONJUNCTIVITIS
8. PERIPHERAL VASCULAR DISEASE
9. Hemorrhoids
10. SEROUS OTITIS
11. BENIGN PROSTATIC HYPERTROPHY
12. HYPERTENSION
13. Right Colon Cancer
14. Rectal ulcers
15. MDS
Social History:
Violinist, no alcohol, no drug use
Family History:
No colon cancer history.
Physical Exam:
ADMISSION EXAM:
VS: T-100.6, HR-105, BP-93/46, RR-16, Sats-98% 3L/NC
HEENT: pale conjunctiva, anicteric, + oral thrush, dry mucosa
Neck: supple, no lymphadenopathy, no JVD
CV: tachy, 2/6 SEM @ LUSB, no S3/S4
Pulm: CTA bilat, no wheeze/rales/rhonchi
Abd: soft, hyperactive bowel sounds, nontender, no
rebound/guarding, ileostomy pink with green stool in bag,
vertical abdominal wound healing
Ext: no edema, warm, 1+ bilat DP, 2+ bilat Radial pulses
Skin: no rash
Pertinent Results:
[**2135-7-19**] 03:36AM BLOOD WBC-40.1* RBC-3.66* Hgb-11.1* Hct-32.5*
MCV-89 MCH-30.3 MCHC-34.3 RDW-18.5* Plt Ct-82*
[**2135-7-18**] 03:33PM BLOOD Hct-31.8*
[**2135-7-18**] 02:48AM BLOOD WBC-38.5* RBC-3.47* Hgb-10.9*# Hct-29.6*
MCV-85 MCH-31.4 MCHC-36.8* RDW-18.4* Plt Ct-71*
[**2135-7-17**] 01:19PM BLOOD Hct-23.9*
[**2135-7-17**] 04:35AM BLOOD WBC-47.9* RBC-2.79* Hgb-8.2* Hct-24.4*
MCV-88 MCH-29.5 MCHC-33.7 RDW-19.1* Plt Ct-92*
[**2135-7-16**] 06:38PM BLOOD WBC-57.8* RBC-2.67* Hgb-8.1* Hct-24.5*
MCV-92 MCH-30.2 MCHC-32.9 RDW-17.3* Plt Ct-108*
[**2135-7-18**] 02:48AM BLOOD Neuts-67 Bands-4 Lymphs-4* Monos-18*
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-2* Hyperse-2*
[**2135-7-17**] 04:35AM BLOOD Neuts-66 Bands-4 Lymphs-5* Monos-23*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2135-7-16**] 06:38PM BLOOD Neuts-56 Bands-9* Lymphs-6* Monos-28*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2135-7-18**] 01:00PM BLOOD LAP-PND
[**2135-7-19**] 03:36AM BLOOD Glucose-136* UreaN-48* Creat-0.7 Na-141
K-3.3 Cl-113* HCO3-16* AnGap-15
[**2135-7-18**] 02:48AM BLOOD Glucose-177* UreaN-54* Creat-0.9 Na-139
K-4.0 Cl-113* HCO3-16* AnGap-14
[**2135-7-17**] 04:35AM BLOOD Glucose-139* UreaN-50* Creat-1.1 Na-139
K-4.5 Cl-113* HCO3-16* AnGap-15
[**2135-7-16**] 06:38PM BLOOD Glucose-133* UreaN-69* Creat-1.6* Na-132*
K-5.3* Cl-103 HCO3-20* AnGap-14
[**2135-7-19**] 12:10PM BLOOD CK(CPK)-PND
[**2135-7-19**] 03:36AM BLOOD CK(CPK)-11*
[**2135-7-18**] 07:08PM BLOOD CK(CPK)-15*
[**2135-7-18**] 02:48AM BLOOD ALT-80* AST-24 LD(LDH)-259* AlkPhos-129*
Amylase-96 TotBili-0.8 DirBili-0.3 IndBili-0.5
[**2135-7-17**] 04:35AM BLOOD ALT-100* AST-29 CK(CPK)-17* AlkPhos-151*
Amylase-125* TotBili-1.1
[**2135-7-16**] 06:38PM BLOOD ALT-129* AST-40 CK(CPK)-7* AlkPhos-196*
Amylase-216* TotBili-1.0
[**2135-7-18**] 02:48AM BLOOD Lipase-84*
[**2135-7-17**] 04:35AM BLOOD Lipase-81*
[**2135-7-16**] 06:38PM BLOOD Lipase-160* GGT-529*
[**2135-7-19**] 12:10PM BLOOD CK-MB-PND cTropnT-PND
[**2135-7-19**] 03:36AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2135-7-18**] 07:08PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2135-7-17**] 04:35AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2135-7-16**] 06:38PM BLOOD CK-MB-1 cTropnT-0.12*
[**2135-7-18**] 02:48AM BLOOD Albumin-3.0* Calcium-7.9* Phos-5.0*
Mg-2.0
[**2135-7-17**] 04:35AM BLOOD Albumin-2.9* Calcium-7.0* Phos-4.6*
Mg-1.8
[**2135-7-16**] 06:38PM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.1 Mg-2.0
UricAcd-7.9*
[**2135-7-18**] 02:48AM BLOOD Hapto-121
[**2135-7-16**] 06:38PM BLOOD CRP-4.24*
[**2135-7-16**] 10:04PM BLOOD Type-ART pO2-128* pCO2-33* pH-7.34*
calHCO3-19* Base XS--6 Comment-GREEN TOP
Brief Hospital Course:
By Problem:
PLAN:
#Shock:
Suspect due to sepsis.
source: intra-abdominal abscess vs old PICC line
-Bolused to goal CVP 8-12.
-MAP<65, added Levophed.
-Stress dosed steroids; random [**Last Name (un) 104**] 38.9. Changed back to home
dose on [**7-19**].
-Keep HCT>30 with transfusions.
-Covered with antibiotics Vanco/Ceftaz/Flagyl, to cover ?MRSA
line inf/possible abd source.
- [**7-16**] CT abdomen --> no cholecystitis, 22 mm fluid pocket near
wound - not considered significant source of infection by
surgery.
#ARF:
Likely secondary to pre-renal azotemia. Urine sediment
examined--> no muddy brown casts, so doubt ATN.
-F/u urine lytes.
-Renally dose all medications.
-Held ACEi/aldactone.
-[**7-18**] creatinine down to 0.7 and doing great. Can restart ACE
and aldactone.
# ID:
[**7-18**] d/c'ed flagyl- continuing on ceftaz and vanco for 14 day
course to treat presumed PICC line infection.
#?Subclavian artery puncture:
Review of blood gases sent from ED showed PaO2>100. ?arterial
line.
-CT shows in correct place
-Vascular rec d/c line --> d/c on [**7-17**]
-check echo to look for shunt - no shunt identified.
#Anemia:
?blood loss, renal failure, or related to h/o MDS.
-Keep HCT>30.
-Continue EPOGEN.
- got 4uPRBCs on [**7-17**].
- stable Hct since.
#ITP:
-Continue steroids.Changed back to home dose on [**7-19**].
-Follow plt count.
#MDS:
-No atypical cells in diff, but would check manual diff given
leukocytosis.
#LFT abnormalities:
-?Cholestasis - CT negative for cholecystitis
-Follow LFTs
- [**Month (only) 116**] be [**1-10**] TPN.
#Cardiac:
-Pt with ST dep in precordial leads on admission EKG.
-Follow enzymes-CP [**2135-7-17**]-ruling out again.
-AM EKG.
echo [**7-17**] ef >55%, mod systolic htn, 3+ Mr.
- having transient brady episodes on lopressor -continue it.
#Coagulopathy:
-INR 1.6, likely [**1-10**] poor nutrition.
-Given Vit K.
#Prophylaxis:
-Pneumoboots.
-PPI.
#FEN:
-Kept NPO on admission for possible procedures. Advanced diet
and pt tolerating PO's.
-TPN to supplement PO as pt has poor PO intake and low albumin.
#Access:
-L PIV.
#Comm:
[**Name (NI) 1094**] family: [**Telephone/Fax (1) 7826**] (home)
cell: [**Telephone/Fax (1) 7827**] ([**Doctor First Name **])
#FULL CODE.
Medications on Admission:
Atenolol 25mg QD
Lisinopril 40mg QD
Aldactone 25mg [**Hospital1 **]
Terazosin 2mg QHS
Prednisone 20mg QOD
Prevacid 30mg [**Hospital1 **]
FeSO4 325mg TID
EPOGEN 5000 units Mon/Wed/Fri
Insulin
TPN
Xalatan
Tobradex
Cosopt
Discharge Medications:
Vancomycin 1g IV Q24h - Day #[**3-23**]
Ceftazidime 2g IV Q12h - Day #[**3-23**]
Bactrim DS 1 tab PO Mon/Wed/Fri - PCP prophylaxis due to
suppressed immunity.
Resume outpatient medications.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Sepsis
Discharge Condition:
Good, stable.
Discharge Instructions:
Continue antibiotics (Vancomycin/Ceftazidime) for full 14-day
course.
Followup Instructions:
Follow-up with physicians at [**Hospital6 **] Hospital
upon transfer.
|
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801
| 187,764
|
50407
|
Discharge summary
|
report
|
Admission Date: [**2197-6-19**] Discharge Date: [**2197-8-3**]
Date of Birth: [**2151-2-17**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Demerol / Penicillins
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
RLQ pain
Major Surgical or Invasive Procedure:
1. Renal biopsy - [**2197-6-21**]
2. Endotracheal intubation
3. Tracheostomy
4. PEG
5. Central venous line placement - removed
6. Arterial line placement - removed
7. PICC line placement
History of Present Illness:
Mrs. [**Known lastname 105043**] is a 46F with PMH significant for FSGS s/p live
donor renal transplant in [**2182**], on CSA and prednisone, with h/o
ureteral stricture s/p multiple stentings by urology service,
last in [**3-9**]. She presents today with few days h/o RLQ pain
(over transplanted kidney site), chills, and dysuria, with
nausea, but no vomiting. She did have some non-bloody loose
stools 2 days ago, for which she took immodium x 1, and
resolved. She was also noted to have worsening of her her renal
function, with elevation of her BUN/Cr to 35/3.0, from baseline
creatinine 2.2. Her creatinine has been gradually worsening over
the past year, from 1.8 in [**4-7**] to 2.2 on [**2197-3-8**], to 2.5 on
[**2197-4-26**]. She last saw Dr. [**Last Name (STitle) 3271**] in clinic in [**3-9**], at which
point he asked her to decrease her CSA dose from 100mg PO bid to
100mg PO qD alternating with 200mg PO qD; however, per her
report, she has continued to take 100mg PO bid. Last CSA level
264 on [**4-26**].
.
In the ED, her initial VS were T 99.3F, BP 170/82, HR: 105, RR:
18, Satting 94% on RA. She was found to have a slightly elevated
wbc to 11.1 (68% PMN), and, as above, BUN/Cr of 35/3.0. A
transplant renal U/S was done, which demonstrated no evidence of
hydronephrosis, normal vascular flow and indices, and no fluid
collections. Lactate was 1.8. UA demonstrated small blood, small
LE, neg nitr, 3-5wbc with 0-2rbc, few bacteria, 0 epi. A repeat
UA was sent, which was similar, except demonstrating 0-2 wbc.
Renal service saw her in the ED, and recommended Levofloxacin
500mg PO x 1, followed by 250mg PO q48h, and 1L NS, which she
received. Pt deferred pelvic exam. Also recommended were urine
lytes (FENa 1.95%), LFTs/amylase/lipase, which were pending at
time of admission, and transplant surgery consult, who were
notified of her admission. She was admitted to the hepatorenal
service for further inpatient management.
Past Medical History:
1. ESRD s/p living related renal transplant in [**2182**] [**1-5**] single
left kidney and focal glomerulosclerosis; c/b ureteral
stricture, s/p ureteral stent placement, last exchanged [**6-7**]
2. hypertension
3. depression
4. chronic pain
5. hyperlipidemia
6. endometriosis
7. severe gastroparesis on [**2193**] gastric emptying study
Social History:
Significant for a 20 pack per year history of tobacco. Denied
any alcohol or IVDU. She lives with her husband and son.
Family History:
NC
Physical Exam:
VS: T: 98.4F BP: 196/90 HR: 84 RR: 18 SaO2: 100% RA
Gen: Lying comfortably in bed, mild abd distress
HEENT: PERRL, MMM
CV: RRR, nl S1 and S2, no m/r/g
Chest: CTAB, no w/r/r
Abd: Soft, mildly TTP over transplant kidney site
Extr: no LE edema, 1+ DPs bilaterally
Neuro: A&Ox3, no asterixis
Pertinent Results:
Admission Labs:
.
[**2197-6-19**] 02:05PM PLT COUNT-197
[**2197-6-19**] 02:05PM NEUTS-68.1 LYMPHS-26.8 MONOS-3.4 EOS-1.0
BASOS-0.7
[**2197-6-19**] 02:05PM WBC-11.1* RBC-4.71 HGB-14.7 HCT-41.4 MCV-88
MCH-31.3 MCHC-35.6* RDW-13.9
[**2197-6-19**] 02:05PM URINE GR HOLD-HOLD
[**2197-6-19**] 02:05PM URINE UHOLD-HOLD
[**2197-6-19**] 02:05PM URINE HOURS-RANDOM
[**2197-6-19**] 02:05PM URINE HOURS-RANDOM
[**2197-6-19**] 02:05PM ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-3.6
MAGNESIUM-1.8
[**2197-6-19**] 02:05PM LIPASE-47
[**2197-6-19**] 02:05PM ALT(SGPT)-9 AST(SGOT)-15 ALK PHOS-115
AMYLASE-57 TOT BILI-0.5
[**2197-6-19**] 02:05PM GLUCOSE-92 UREA N-35* CREAT-3.0* SODIUM-139
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
[**2197-6-19**] 02:17PM K+-4.6
[**2197-6-19**] 04:37PM LACTATE-1.8
[**2197-6-19**] 04:37PM COMMENTS-GREEN TOP
[**2197-6-19**] 05:15PM URINE RBC-0-2 WBC-[**2-5**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2197-6-19**] 05:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2197-6-19**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2197-6-19**] 05:15PM URINE UHOLD-HOLD
[**2197-6-19**] 05:15PM URINE HOURS-RANDOM
[**2197-6-19**] 05:27PM CYCLSPRN-494*
[**2197-6-19**] 06:19PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2197-6-19**] 06:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2197-6-19**] 06:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2197-6-19**] 06:19PM URINE UHOLD-HOLD
[**2197-6-19**] 06:19PM URINE HOURS-RANDOM CREAT-41 SODIUM-37
POTASSIUM-14 CHLORIDE-23
Pertinent Labs/Studies:
.
WBC: 11.1 ->> 24.2 ->> 8.0
Creat: 3.0 ->> 4.0 ->> 1.6
.
[**2197-7-14**] 02:58PM BLOOD calTIBC-178* Ferritn-606* TRF-137*
[**2197-7-8**] 03:30PM BLOOD HIV Ab-NEGATIVE
[**2197-6-25**] 07:58AM BLOOD ANCA-NEGATIVE B
.
.
.
Imaging Studies:
[**2197-6-19**]: Renal US - No evidence of hydronephrosis.
.
[**2197-6-23**]: Echo - IMPRESSION: Normal biventricular global and
regional systolic function. Small pericardial effusion without
echocardiographic signs of tamponade.
.
[**2197-6-26**]: CT C/A/P - IMPRESSION:
1) No perinephric fluid collections or hematoma surrounding the
transplanted kidney.
2) Air in the collecting system of the transplanted kidney and
bladder as
described above.
3) Endotracheal tube position approximately 1cm from the carina.
.
[**2197-7-12**]: CT A/P - IMPRESSION:
1. Diffuse small bowel dilatation. Contrast passes throughout
the colon to the rectum at the time of imaging. Findings are
most consistent with an ileus. If there is concern for
developing small bowel obstruction, serial abdominal radiographs
are reccomended.
2. New small amount of ascites around the liver.
3. Residual droplets of air in the transplant renal collecting
system and
bladder. Nephroureteral stent in place. No hydronephrosis of
the transplant.
.
[**2197-7-5**]: Echo -
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is a small circumferential pericardial effusion with no
echocardiographic signs of tamponade.
.
[**2197-8-2**]: Portable CXR - PORTABLE AP CHEST RADIOGRAPH: Compared
to prior radiograph from [**2197-7-25**]. The area of
consolidation in the right lower lobe has resolved and now
remains residual atelectasis. The left retrocardiac opacity
persists and likely represents consolidated portions of lung.
No pleural effusions are seen. Mild cardiomegaly is unchanged.
No pulmonary vascular congestion or pulmonary edema is seen.
Mediastinal and hilar contours are normal. Tracheostomy tube is
seen in appropriate position. The tip of the left PICC line
overlies the expected region of the mid SVC.
.
IMPRESSION: Resolution of right lower lobe consolidation, now
with residual atelectasis. Persistent left lower
lobe/retrocardiac consolidation.
.
.
Pathology:
[**2197-6-21**]: Renal allograft biopsy - Chronic allograft nephropathy.
There is no evidence of acute cellular rejection in this sample.
The differential diagnosis also includes "acute tubular
necrosis", obstruction, and drug nephrotoxicity. Cortical
sample size is quite limited, and may not be representative of
the organ.
.
.
Microbiology:
.
Blood cultures: [**6-19**]; [**6-23**]; [**6-28**]; [**7-4**], [**7-10**], [**7-15**], [**7-21**],
[**7-24**], [**7-25**]: No growth
[**2197-8-1**]: Pending, no growth to date
.
Urine Cultures: [**7-4**], [**7-5**] -> coag negative staph
[**2197-8-1**]: No growth
.
BAL - [**2197-7-25**] -
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
Cx - 10K -100K Coag + Staph - no sensitivities performed (sputum
revealed MSSA)
.
Sputum - [**2197-7-24**]: 4+ GPC, cx - sparse growth MSSA
[**2197-7-28**] - sparse growth coag + staph (presumed MSSA)
[**2197-8-1**] - cancelled due to OP flora contamination
[**2197-8-2**] - cancelled due to OP flora contamination
.
[**2197-6-21**]: EBV - IgM negative, IgG positive
[**2197-6-21**] ; [**2197-7-29**] - CMV viral load undetectable
.
Stool:
[**7-10**] -> [**2197-8-2**]: C. Diff negative x 10 samples
.
[**2197-6-27**]: Rapid virus screen - negative
Discharge Labs:
.
.
[**2197-8-3**] 05:32AM BLOOD WBC-8.0 RBC-3.01* Hgb-8.6* Hct-26.6*
MCV-89 MCH-28.7 MCHC-32.4 RDW-19.6* Plt Ct-484*
[**2197-8-1**] 03:24AM BLOOD Neuts-15* Bands-9* Lymphs-30 Monos-13*
Eos-24* Baso-1 Atyps-4* Metas-2* Myelos-1* Promyel-1* NRBC-17*
[**2197-7-31**] 03:28AM BLOOD PT-12.8 PTT-26.0 INR(PT)-1.1
[**2197-8-3**] 05:32AM BLOOD Glucose-142* UreaN-54* Creat-1.6* Na-146*
K-4.0 Cl-109* HCO3-29 AnGap-12
[**2197-8-2**] 12:25PM BLOOD ALT-29 AST-23 AlkPhos-99
[**2197-8-2**] 03:55AM BLOOD ALT-26 AST-25 LD(LDH)-272* AlkPhos-89
Amylase-88 TotBili-0.2
[**2197-8-2**] 03:55AM BLOOD Lipase-118*
[**2197-8-3**] 05:32AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8 Iron-PND
[**2197-8-3**] 05:32AM BLOOD Ferritn-PND TRF-PND
Brief Hospital Course:
Assessment: 46F with h/o FSGS s/p liver donor renal transplant
c/b ureteral stricture s/p multiple stentings, presenting with
few days of RLQ pain, chills, and dysuria, and elevation in
creatinine.
.
Her initial course on the medical floor was notable for
persistent acute renal failure. She was cultured and eventually
underwent a renal biopsy that showed chronic allograft
nephropathy. After the renal biopsy pt was noted to have
decreased hct from 40-30, was given 2.5 liters of fluid through
the day, then received 1U PRBC finished at 12am, triggered at
4am for hypoxia, noted to desat to 60s, placed on NRB with
increase of o2 sat to 80s, o/w VS were 98.8 112 144/90 rr 40,
satting 80s on NRB. abg performed showed 7.26/47/74. pt given
40 lasix with increase UO of 140cc/hr then another 200 lasix.
She was treated supportively for possible TRALI and placed on
bipap with increases in her oxygenation to 95%. The remainder
of her course will be by problem.
.
#. Respiratory failure: Felt to be initially be [**1-5**] to TRALI (as
happened around 48 hours after transfusion) did not improve with
diuresis and CXR findings also suggestive. However, ultimate
work up by blood bank was not consistent with this diagnosis.
She was intubated within 12hours of the acute failure on [**6-25**]
and vent settings changed to ARDSNet protocol for lung
protective strategy. A discussion was taken with blood bank and
it seems likely that this was trali initially based on initial
clinical course, but the clinical picutre was confusing given
prolonged course. This incidentally does not effect the ability
to get future transfusions. Her respiratory decompensated
further while on the vent with fevers, elevated WBC and increase
production sputum. MSSA grew from sputum and BAL, and she was
treated initially on vanco and Zosyn but swithced to Nafcillin
on [**7-7**] when sputum returned with MSSA. She was swithced back to
Vancomycin after a Coag negative staph came back in her urine
and completed a total of 8 days of vancomycin. She remained
difficult to wean, felt mainly to be due to volume overload,
agitation requiring heavy sedation (as below) and dense
consolidations from the above MSSA-ventilator associated
pneumonia. As her respiratory failure persisted, a tracheostomy
and J-tube placement was performed on [**7-14**]. From there, a vent
weaned continued, moving her at first to pressure support and
slowly decreasing the support daily. The wean was delayed by a
recurrent MSSA ventilator-associated pneumonia, treated with an
eight-day course of vancomycin (and briefly cefepime for the
first few days; this was stopped after a few days, as below, as
she was felt to be allergic to naficillin). At the time of
discharge, she continued to require intermittent ventilatory
support, but was doing well for hours at a time on trach mask.
While on the ventilator, she appeared quite comfortable on
pressure support of [**9-7**] with 40%fio2, with rr's around 18 and
tidal volumes easily in the 500's. The last few days the patient
has been undergoing trach mask trials. On [**2197-7-31**] she tolerated
12 hours, 5 hours on [**2197-8-1**], and only a few minutes on
[**2197-8-2**]. On [**2197-8-2**] she was placed back on CPAP/PS because of
desat to low 80s. Of note, the last few days prior to discharge
patient has been having low grade temp to 100.5, although
afebrile last 24 hours. Repeat CXR on [**2197-8-2**] revealed
resolution of previously identified right LL opacification but
persistent left retrocardiac opacity. If the patient spikes a
temperature again, consideration should be made towards repeat
treatment of VAP.
.
#. Renal failure: The intial renal failure with which she was
admitted was felt to probably be due to ATN and resolved on its
own back to a baseline Cr of 1.7-2.0. She was continued on her
mycophenolate 500mg po bid and prednisone 5mg daily. However,
on [**7-26**] in the setting of a drug rash, fever, and eosinophilia,
as below, her Cr worsened, eventually peaking at 3.1 on [**7-28**].
This was felt to be due to acute interstitial nephritis; this
responded well to high dose steroids (hydrocortisone 100mg tid x
1 day, then moved to [**Hospital1 **], now 25mg [**Hospital1 **]), with rapid improvement
in Cr back to 1.6 on the day of discharge. As requested by the
renal transplant service, the patient will now be discharged on
Prednisone 5mg po bid and CellCept 500mg IV bid. It has been
requested that the patient have follow up with Dr. [**Last Name (STitle) **] from
transplant within one week at which time decisions towards
appropriate immunsuppressive therapy will be made. The patient
should have Chem panel performed two to three times weekly to
monitor renal function. If there are any abnormalities noted,
Dr. [**Last Name (STitle) **] should be notified please at [**Telephone/Fax (1) 49911**].
.
#. Allergic reaction: On [**7-23**], Mrs. [**Last Name (STitle) 105044**] was noted to have
a truncal erythematous macular rash that became increasingly
intense and confluent, spreading to her face and down her
extremities. She also began spiking fevers and, as above,
developed worsening renal function. Dermatology saw the rash
and felt that naficillin most likey caused this reaction and
that it was worsening because of the cefepime, which was
subsequently stopped. On high dose steroids (mainly started for
probably AIN) and topcial triamcinolone, her rash improved. She
was not given any further beta-lactam based medications.
.
#. Leukopenia: On [**7-25**], Mrs. [**Known lastname 105043**] unexpectedly became
leukopenic, dropping her WBC from 10 to 2. Hematology was
consulted and they felt that this was probably medication
related. Her leukopenia has since resolved.
.
#. Agitation - During her period of ventilation, prior to wean
attempts, the patient was noted to be very agitated, requiring
large doses of Fentanyl, Versed as well as propofol. With
addition of standing Haldol, initially as much as 5mg IV q
6hours plus PRN, the patient was slowly able to be weaned from
sedation over a number of days. She most recently has been
maintained on a Fentanyl 72 hour patch 25mcg/hr, Ativan .5mg [**Hospital1 **]
+ PRN for CIWA > 10 (with little need for PRNs) and Haldol has
been decreased to 5mg [**Hospital1 **]. Weaning attempts have been
complicated by agitation with difficulty dissociating
respiratory discomfort/distress from agitation. it is suspected
that some of her agitation earlier was secondary to withdrawal
from narcotics and benzos given the large amounts she was
requiring previously for adequate sedation while vented. Ongoing
efforts should be made to decrease her Ativan, and Haldol as
possible from standing to PRNs only to off. As mentioned above,
additional consideration towards worsening respiratory status
should be made given persistent left retrocardiac opacity
(atelectasis vs. small effusion vs. PNA)
.
#. Ileus - The patient was intially noted to have some abdominal
pain and distention. CT imaging revealed an ileus, likely
secondary to large opiate requirements. With weaning of sedation
and a trial of Naloxone PO to increase bowel motility, the
patient's Ileus resolved. She is now tolerating tube feeds at
goal of 55/hr.
(of note: after patient was discharged, dose of cellcept changed
to 500mg IV bid per renal. This was communicated to the
receiving rehab)
Medications on Admission:
Cyclosporine 100mg PO qod / 200mg PO qod alternating
Prednisone 2.5mg PO qD
Trazodone 100mg PO qHS
Xanax 1mg PO tid
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Eight (8)
Puff Inhalation QID (4 times a day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation
Q4H (every 4 hours).
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane QID (4 times a day).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
12. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
13. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Fentanyl 12 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
17. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 890**] ([**Numeric Identifier 890**])
units Injection qM/W/F (): Dose recommended by renal.
19. Haloperidol Lactate 5 mg/mL Solution Sig: Five (5) mg
Injection QPM (once a day (in the evening)): please taper as
possible.
20. Prednisone 5 mg Tablet Sig: One (1) Tablet PO twice a day:
Patient needs to follow up with Dr. [**Last Name (STitle) 105045**] ([**Telephone/Fax (1) 49911**])
for for directions towards appropriate taper.
21. Haloperidol Lactate 5 mg/mL Solution Sig: 3-5 mg Injection
[**Hospital1 **] (2 times a day) as needed for agitation.
22. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every
6 hours) as needed: taper off CIWA as tolerated. Can D/C if no
PRN needed > 48 hours.
23. Mycophenolate Mofetil 500 mg IV bid
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
PRIMARY:
1. Respiratory failure, hypoxic
2. Acute on chronic renal failure
3. end stage renal disease s/p living related renal transplant
in [**2182**]
4. Ventilator associated pneumonia
5. s/p renal biopsy
6. s/p tracheostomy
7. s/p j-tube placement
8. Leukopenia, resolved
9. Drug rash, resolved
10.Anemia
SECONDARY
- hypertension
- depression
- chronic pain
- hyperlipidemia
- endometriosis
- severe gastroparesis
Discharge Condition:
Stable - ventilated (with tracheostomy), on tube feeds.
.
Vent settings: Pressure support ventilation, 10 (insp)/5 (exp),
40% FiO2 with daily trials of trach mask
Discharge Instructions:
1. Please continue to take all medications as prescribed.
2. Please keep all outpatient appointments
3. If you experience any worsening fever, cough, sputum
production, or worsening in your vent settings, please seek
medical attention.
Followup Instructions:
1. Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within
two weeks of discharge from the rehab facility. Please call his
office at [**Telephone/Fax (1) 34354**] to make an appointment.
.
2. Patient requires follow up with Dr. [**Last Name (STitle) **]. Transplant has
requested the patient be seen within one week. Unfortunately,
this appointment could not be made prior to discharge. Please
call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7749**] at [**Telephone/Fax (1) 68830**] (nurse who can help arrange
scheduling) to make this appointment. If any difficulty, please
call [**Telephone/Fax (1) 49911**] to arrange an appointment. Patient will
require appropriate transportation. Thank you
.
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. Date/Time:[**2197-9-6**] 3:30.
if you are unable to make this appointment, please call Dr. [**Name (NI) 105046**] office at ([**Telephone/Fax (1) 68978**] to reschedule an appointment.
|
[
"580.89",
"288.0",
"996.81",
"584.9",
"285.21",
"560.1",
"995.91",
"403.91",
"V09.0",
"536.3",
"518.4",
"276.4",
"998.11",
"E930.5",
"693.0",
"999.9",
"518.81",
"790.01",
"041.11",
"038.9",
"112.2",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.04",
"99.15",
"99.04",
"46.39",
"96.72",
"89.62",
"55.23",
"33.24",
"93.90",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
19692, 19772
|
9797, 17178
|
305, 494
|
20233, 20398
|
3322, 3322
|
20684, 21761
|
2991, 2995
|
17344, 19669
|
19793, 20212
|
17204, 17321
|
20422, 20661
|
9063, 9774
|
3010, 3303
|
257, 267
|
522, 2468
|
3338, 5275
|
2490, 2836
|
2852, 2975
|
5292, 9047
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,728
| 182,098
|
26188+57484
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-10-30**] Discharge Date: [**2112-11-8**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Transferred from Outside Hospital for GI Bleed and Cholecystitis
Major Surgical or Invasive Procedure:
1. Laparoscopy.
2. Laparotomy.
3. Partial cholecystectomy with stone extraction and
fulguration of gallbladder.
4. Repair of iatrogenic colotomy
History of Present Illness:
This was an 87 year-old man who approximately one week earlier
had entered an outside hospital with right upper quadrant pain
for 2 days and mild elevation of his liver function tests. An
ultrasound at that time showed a thickened gallbladder with
inflammatory changes consistent with cholecystitis. The common
bile duct was dilated to 9 mm. He was thought to have sludge and
possibly small stones in the distal common bile duct on the
ultrasound. At that time, he was placed on Unasyn. At 48 hours
of hospitalization, he suffered an acute upper
gastrointestinal hemorrhage. He ultimately received 6 units
of transfusion over the next 48 hours. He underwent 3
separate upper endoscopies during that time. He was found to
have a bleeding duodenal ulcer at one point which was
cauterized. He also was found to have several scattered
erosive lesions of the stomach which were thought possibly to
be consistent with arteriovenous malformations. These were
also cauterized at that time. Dr. [**Last Name (STitle) 519**] was called by a general
surgeon from the [**Hospital6 3872**], requesting
transfer to our hospital 4 days prior to the present
procedure. He had another episode of melena that morning. The
patient was [**Hospital 25376**] transferred to [**Hospital1 18**] for higher level of
care.
Past Medical History:
Afib - started on coumadin [**8-8**]
CAD s/p CABGx2
CRI
Glaucoma
TIA/CVA
Prostate cancer s/p XRT
Hip replacement [**2101**]
Social History:
Quit smoking 45 years ago, 1 drink/day, no drugs
Physical Exam:
Upon arrival by ambulance, the patient was afebrile with stable
vitals.
He was no in distressed. He was alert and oriented, able to
carry out coherent conversations.
His heart was regularly irregular, with normal S1 and S2.
Lungs were clear to ascultation, bilaterally.
His abdomen was soft with RUQ tenderness without Muprhy's sign.
He had no rebound or guarding.
He did not have any clubbing, edema, or cyanosis on his
extremities. He had good capillary refills.
Neurologically, he was alert and oriented x 3. Cranial nerves
[**1-16**] were grossly intact. Extraocular muscles intact. Right
pulpil dilated from glaucoma medication. Strength was [**4-7**] in all
extremities. His sensation was grossly intact.
Pertinent Results:
PATHOLOGY STILL PENDING
[**2112-11-7**] 06:55AM BLOOD WBC-7.7 RBC-3.41* Hgb-10.7* Hct-31.6*
MCV-93 MCH-31.5 MCHC-34.0 RDW-14.9 Plt Ct-220
[**2112-11-2**] 03:49AM BLOOD ALT-63* AST-49* LD(LDH)-159 AlkPhos-183*
Amylase-96 TotBili-1.1
[**2112-10-30**] 09:06PM BLOOD WBC-7.9 RBC-3.34* Hgb-10.4* Hct-28.6*
MCV-86 MCH-31.1 MCHC-36.3* RDW-15.0 Plt Ct-90*
[**2112-10-30**] 09:06PM ALT(SGPT)-93* AST(SGOT)-82* CK(CPK)-48 ALK
PHOS-289* AMYLASE-59 TOT BILI-2.3*
Brief Hospital Course:
Upon arrival at [**Hospital1 18**], Mr. [**Known lastname 64907**] was immediately admitted to the
Intensive Care Unit for close monitoring. He spent several days
in the ICU without needing a transfusion and was subsequently
transferred to the surgical floor. Once his hematocrit was
stablized, he was taken to the operating room for a
cholecystectomy. He tolerated the procedure well.
Post-operatively, he was deconditioned and needed physical
therapy. He was slow to gain his appetite. However, he
eventually came around to tolerate a regular diet. Since his
surgery, he has been afebrile with stable vitals, producing
adequate urine. His hematocrit has been stable. He has been
working with a physical therapist to improve his strenght. He
will be discharged [**2112-11-8**], in stable condition, to a
rehabilitation center to complete his full recovery.
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. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4
hours) as needed.
8. Disopyramide 150 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6HRS
().
10. Folic Acid Oral
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
12. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
13. Potassium Chloride 20 mEq Packet Sig: One (1) PO DAILY
(Daily).
14. Metoprolol Tartrate 5 mg/5 mL Solution Sig: [**12-6**] Intravenous
Q 6 PRN () as needed.
15. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**]
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Stable/Good
Discharge Instructions:
Please take medications as prescribed and read warning labels
carefully. Please follow directions instructed by Dr. [**Last Name (STitle) 519**]
earlier.
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
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.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] in [**12-6**] weeks. Call [**Telephone/Fax (1) 6554**]
for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2112-11-8**] Name: [**Known lastname 11443**],[**Known firstname 400**] H Unit No: [**Numeric Identifier 11444**]
Admission Date: [**2112-10-30**] Discharge Date: [**2112-11-8**]
Date of Birth: [**2025-8-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5964**]
Addendum:
added on "follow-up appointments": Please do not forget to
make an appointment ([**Telephone/Fax (1) 11445**]) with Dr. [**Name (NI) 11446**] for
a repeat EGD (esophageal-gastric-duodenal endoscopy) in [**3-9**]
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2057**] - [**Location (un) 4887**]
[**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**]
Completed by:[**2112-11-8**]
|
[
"427.31",
"E878.6",
"V58.61",
"397.0",
"574.00",
"V45.81",
"V64.41",
"998.2",
"585.9",
"532.40",
"V10.46",
"574.10",
"537.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.21",
"46.75",
"51.85",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7529, 7765
|
3255, 4123
|
327, 473
|
5615, 5629
|
2773, 3232
|
6602, 7506
|
4146, 5466
|
5578, 5594
|
5653, 6579
|
2030, 2754
|
223, 289
|
501, 1801
|
1823, 1949
|
1965, 2015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,935
| 155,383
|
24591
|
Discharge summary
|
report
|
Admission Date: [**2106-6-13**] Discharge Date: [**2106-6-21**]
Service: MEDICINE
Allergies:
Lipitor / Codeine / Procardia / Iodine / Pepcid / Catapres /
Humibid E / Shellfish / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
89F CAD c 3vd s/p stenting, mesenteric ischemia, EF 30%, ppm for
sss, thrombocytosis p/w worsening angina for elective cath. She
states that her anginal chest pain has become worse over the
past several months. In the past week, she has anginal CP
roughly twice per week, associated with SOB, relieved by SL NTG
with attacks occuring usually with light walking around the
house, though sometimes at rest. At her baseline, she rarely
leaves the house and rarely does stairs, and she becomes
fatigued walking around the house. She uses a [**First Name3 (LF) **] to nagivate
the driveway to get to the car. On friday, she had three
episodes of CP in a several hour period. She was seated after
recently eating a tuna [**Location (un) 6002**] had dull pain across the chest
associated with fatigue and SOB. This was relieved with NTG SL,
then recurred an hour later when walking to the bathroom and was
relieved again with NTG. After a similar episode an hour later,
she called her doctor. Dr. [**Last Name (STitle) **] recommended that she come in
for an elective catheterization.
Past Medical History:
#. CAD: 3vd s/p multiple PCI
#. Congestive Heart Failure:
-- Echo [**2104-5-9**]: LVEF <30%, Anterior, septal, apical, distal
inferior, and distal lateral severe hypokinesis to akinesis.
#. 2+ MR.
#. Some notes mention a possible history of Atrial Fibrillation
#. Sick Sinus Syndrome s/p pacemaker
#. Hypertension
#. Hyperlipidemia
#. Essential thrombocytosis
#. Chronic mesenteric ischemia: mesenteric angiogram on
[**2104-7-29**] and received stent to celiac artery origin which had
90% stenosis. Pt's GI doctor is Dr. [**Last Name (STitle) **] at [**Hospital1 **]
#. chronic pancreatitis
#. Hypothyroidism
Social History:
Lives with son, has [**Name2 (NI) **] though uses only when she leaves the
house which is not frequent.
Patient denies any tobacco, EtOH or IV drug use.
significant for the absence of current tobacco use. There is no
history of alcohol abuse.
Family History:
Mother - died at age 72, lung ca
Father - died at age 62, lung ca
3 children - 1 son w/ lung ca; daughter [**Name (NI) **] [**Last Name (NamePattern1) **] in [**Location (un) 86**]
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 98.6 BP 162/54 HR 61 RR 20 30 RAO2 54.8 kg
Gen: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP flat
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: Petechia RLE, no stasis dermatitis, ulcers, scars, or
xanthomas.
Pertinent Results:
[**2106-6-13**] 04:50PM GLUCOSE-77 UREA N-38* CREAT-1.7* SODIUM-142
POTASSIUM-5.1 CHLORIDE-111* TOTAL CO2-20* ANION GAP-16
[**2106-6-13**] 04:50PM estGFR-Using this
[**2106-6-13**] 04:50PM CK(CPK)-25*
[**2106-6-13**] 04:50PM CK-MB-NotDone cTropnT-<0.01
[**2106-6-13**] 04:50PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.3
IRON-35
[**2106-6-13**] 04:50PM calTIBC-226* FERRITIN-114 TRF-174*
[**2106-6-13**] 04:50PM WBC-4.7 RBC-3.28* HGB-12.3 HCT-38.6 MCV-118*#
MCH-37.6* MCHC-32.0 RDW-20.3*
[**2106-6-13**] 04:50PM PLT COUNT-545*
[**2106-6-13**] 04:50PM PT-14.4* PTT-24.8 INR(PT)-1.3*
[**2106-6-21**] 07:50AM BLOOD WBC-3.5* RBC-2.92* Hgb-10.7* Hct-35.4*
MCV-121* MCH-36.6* MCHC-30.2* RDW-19.6* Plt Ct-584*
[**2106-6-19**] 07:55AM BLOOD Neuts-86* Bands-0 Lymphs-9* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2106-6-21**] 07:50AM BLOOD Plt Ct-584*
[**2106-6-20**] 07:40AM BLOOD PT-13.8* PTT-29.1 INR(PT)-1.2*
[**2106-6-21**] 07:50AM BLOOD Glucose-78 UreaN-45* Creat-1.5* Na-143
K-5.1 Cl-114* HCO3-20* AnGap-14
[**2106-6-16**] 03:09AM BLOOD CK(CPK)-16*
[**2106-6-16**] 03:09AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2106-6-21**] 07:50AM BLOOD Mg-2.5
[**2106-6-20**] 07:40AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.6
[**2106-6-13**] 04:50PM BLOOD calTIBC-226* Ferritn-114 TRF-174*
[**2106-6-16**] 07:16AM BLOOD Type-ART Temp-35.6 Rates-/22 O2 Flow-3
pO2-66* pCO2-28* pH-7.41 calTCO2-18* Base XS--4
Intubat-INTUBATED Comment-NASAL [**Last Name (un) 154**]
[**2106-6-15**] 09:57PM BLOOD Lactate-2.4*
[**2106-6-16**] 07:16AM BLOOD Lactate-6.0*
[**2106-6-16**] 12:38PM BLOOD Lactate-2.1*
[**2106-6-15**] 08:42PM BLOOD O2 Sat-94
.
.
Echo [**2106-6-17**]:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to hypokiesis of the interventricular
septum. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. Right
ventricular systolic function is normal. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**2-9**]+) mitral regurgitation is
seen. The mitral regurgitation jet is eccentric. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is a small posterolateralpericardial
effusion. There are no echocardiographic signs of tamponade.
.
Compared with the findings of the prior study (images reviewed)
of [**2104-6-2**], the left ventricular ejection fraction is
increased.
.
Cardiac Cath [**2106-6-15**]:
COMMENTS: 1. Selective coronary angiography in this right
dominant
patient revealed three vessel CAD. The RCA was diffusely
diseased with
a mid occlusion. The LMCA had a 30% lesion. The LAD had a 90%
lesion
distal to the two previously placed stents. The LCX had a 80%
proximal
and a 80% distal lesion.
2. Limited hemodynamics revealed systemic hypertension with
pressures
of 191/64 with HR 60 in sinus.
3. Successful PTCA and stnting of the RLADwith a 3.00 Cypher
DES. The
final angiogram demonstrated no residual stenosis with no
angiographic
evidence of dissection, embolization or perforation with TIMI
III flow
in the distal vessel. (See PTCA comments)
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Systemic hypertension
3. Successful PCI of the LAD.
Brief Hospital Course:
Pt is a 89F CAD c 3vd s/p stenting, mesenteric ischemia, EF 30%,
ppm for sss, thrombocytosis p/w worsening angina for elective
cath
.
#) CAD:
There is a history of 3vd with multiple previous PCIs. She now
presented with worsening of stable anginal symptoms for elective
catheterization. The patient required CCU transfer after the
catherization after developing SOB during the catheterization
requiring NRB mask. The cath showed a right dom. system with
LMCA 30% lesion, LAD 90% lesion (stented with a taxus stent),
lcx 80% prox/80% distal, occluded RCA. The SOB was suspected due
to a combination of volume overload and dye reaction given her
known history of shellfish allergy. She did receive appropriate
pretreatment prophylaxis. CXR showed CHF and she was diuresed
and her volume status and creatinine improved to her baseline.
She was continued on asa, plavix, BB, and nitro patch. She is
not on a statin as a part of her outpatient regimen and it is
notable that last her LDL was 65 on [**2104-12-26**]. Her symptoms of
chest pain remained inactive during the hospital stay.
.
#) Rhythm: SSS s/p pacer
#) Pump:
She became volume overloaded after the catheterization as noted
above and then was subsequently diuresed until she reached
euvolemia. She has an EF of 30%. She was continued on her
beta-blocker, though the ACE was held for renal protection
.
#) CRI:
Cr bumped in the setting of her clinical decompensation after
the catheterisation although this subsequently returned to near
baseline 1.5. She received bicarb/mucomyst pretreatment for cath
and the ACE was held.
.
#) Anemia:
hct remained stable.
.
#) Essential thrombocytosis:
Platelets were noted to be in the 500s to 600s during the
hospitalization. They were 1000 in [**2104-7-9**] and she was
susequently controlled on outpatient hydrea. Hem/Onc consultants
followed along during the hospital stay and in their assessment,
the platelet elevation from her previous outpatient baseline was
likely due to acute illness. The recommended only slight dose
adjustments in the hydrea when the creatinine bumped after the
clinical decompensation noted above. She will need to follow-up
with heme/onc to continue to monitor WBC and platelet counts on
hydrea.
.
# hypothyroid: c/w synthroid
#) FEN: cardiac diet
.
#) PPX: hep SC, PPI
#) Access: PIVs
#) Code: full
#) Contacts: Son [**Telephone/Fax (1) 62092**] home, [**Telephone/Fax (1) 62093**] cell
Medications on Admission:
Norvasc 5 mg qAM, 2.5 qHS
Levothyroxine 25 mcg PO DAILY
Methyldopa 500 mg PO 3X a day
Enalapril 20 mg PO twice a day
Furosemide 40 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Metoprolol 100 mg 1 Tablets PO TID
Aspirin 81 mg DAILY
Hydroxyurea 500 mg PO One capsule q T, Th
Hydroxyurea 500 mg Two Capsule PO q M,W,F, Sa, [**Doctor First Name **]
Nitro patch
Loperamide 2 mg PO TID as needed for diarrhea
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methyldopa 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Transdermal
once a day: Place patch at 9pm daily, take patch off at 3pm
daily.
8. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO QTUES
(every Tuesday).
11. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 6X/WEEK
([**Doctor First Name **],MO,WE,TH,FR,SA).
12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-9**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 INH* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Angina
Coronary Artery Disease
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Take all medications as prescribed
.
Follow up as per below
.
Seek medical attention immediately if you experience new
symptoms including chest pain, shortness of breath, arm or jaw
numbness, fainting, palpitations or other concerning symptoms.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 17568**]. Please call for a follow up
appointment within 2 weeks.
.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:
[**2106-7-8**] 1:00
|
[
"238.71",
"413.9",
"424.0",
"428.0",
"V45.01",
"403.90",
"244.9",
"585.9",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"36.07",
"88.52",
"37.22",
"00.40",
"00.66",
"88.55",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
11161, 11220
|
7231, 9648
|
323, 337
|
11295, 11304
|
3394, 7093
|
11699, 12052
|
2352, 2615
|
10096, 11138
|
11241, 11274
|
9674, 10073
|
7110, 7208
|
11328, 11676
|
2630, 3375
|
273, 285
|
365, 1444
|
1466, 2076
|
2092, 2336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,366
| 107,273
|
35935
|
Discharge summary
|
report
|
Admission Date: [**2108-11-1**] Discharge Date: [**2108-11-1**]
Date of Birth: [**2064-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Elevated cardiac enzymes suggestive of an NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Dr. [**Known lastname 1140**] is a 43 year-old man with a history of GERD who
presents with pleuritic pain and elevated troponin.
Approximately 6 weeks prior to admission patient hurt his low
back afters slipping; he began using high doses of NSAIDs
(ibuprofen 800mg TID with toradol). On [**10-9**], he noted a "warm"
feeling in his chest which lasted seconds; there may have been
some associated nausea but no SOB or overt CP. From [**2027-10-11**] he
was in [**State 108**] during which time he experienced two further
episodes, similar in nature.
Approximately 1.5 weeks prior to admission, he began also
feeling abdominal pain and occasional sensations that something
was getting stuck in his throat. He spoke with his cardiologist
who ordered an ETT. This was done on [**10-26**] and returned normal
(13 minutes with HR up to 160+). The following day he felt
burning and reflux and induced vomiting to alleviate the
symptoms. Two days later he spoke with a gastroenterologist and
was told he may have eosinophilic esophagitis. Over the last
couple days he has experienced right lower pleuritic chest pain.
On the day of admission he was at work and ate stir fry. He
began feeling as though "food was lined up in the stomach"
though he was hungry. He then presented to the ED at his place
of work.
At the OSH ED he was found to have a troponin I of 0.51 and CK
of 89; aspirin, plavix and heparin gtt were started and he was
transferred for further evaluation.
In the ED, VSS with HR in the 60s and blood pressure in 120s
systolic. Given persistent symptoms, nitro gtt was started.
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. He reports frequent
"gas" and recent low back pain with radiation down the right
leg, improved of late.
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:
1. CARDIAC RISK FACTORS:
(-) Diabetes
(-) Dyslipidemia
(-) Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PCI: None.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
- GERD
- Exercise induced asthma
- Psoriasis
- s/p tonsillectomy, bilateral hernia repair
- Colonoscopy at age 40; normal
Social History:
-Anesthesiologist at [**Hospital3 3583**]
-Tobacco history: None.
-ETOH: Rare.
-Illicit drugs: None.
Family History:
Brother and father with [**Name (NI) 38400**]. No history of early CAD. Father
is otherwise healthly at age 70. GF with leukemia; other GF
with prostate v. colon cancer.
Physical Exam:
VS: T= BP=113/53 HR=67 RR=12 O2 sat=97% RA
GENERAL: Lying in bed, mildly groggy after receiving morphine.
In no distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Cyst noted on lateral
knee on the left.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2108-11-1**] 07:58AM GLUCOSE-164* UREA N-20 CREAT-1.0 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2108-11-1**] 07:58AM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.1
[**2108-11-1**] 07:58AM CK(CPK)-62
[**2108-11-1**] 07:58AM CK-MB-NotDone cTropnT-0.11*
[**2108-11-1**] 07:58AM WBC-7.4 RBC-4.15* HGB-12.5* HCT-34.6* MCV-83
MCH-30.1 MCHC-36.1* RDW-13.2
[**2108-11-1**] 07:58AM NEUTS-63.6 LYMPHS-19.5 MONOS-4.2 EOS-12.3*
BASOS-0.4
[**2108-11-1**] 07:58AM PT-15.0* PTT-150* INR(PT)-1.3*
[**2108-11-1**] 12:40AM CK(CPK)-80
[**2108-11-1**] 12:40AM cTropnT-0.11*
[**2108-11-1**] 12:40AM WBC-7.7 RBC-4.46* HGB-13.5* HCT-37.7* MCV-85
MCH-30.2 MCHC-35.7* RDW-13.5
[**2108-11-1**] 12:40AM NEUTS-53.4 LYMPHS-28.6 MONOS-4.5 EOS-13.0*
BASOS-0.5
[**2108-11-1**] 12:40AM PT-14.3* PTT-104.0* INR(PT)-1.2*
STUDIES:
ETT ([**2108-10-26**]): Reported normal per patient.
EKG: NSR. Normal axis/intervals. No ST-T changes.
CXR ([**11-1**]): 1. No radiographic evidence of pneumonia or acute
CHF.
2. Minimal scarring or atelectasis in the left lung base.
TTE ([**11-1**]): The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormality seen.
Cardiac cath ([**11-1**]):
1. Selective coronary angiography of this right dominant system
revealed no angiographically apparent flow limiting epicardial
coronary
artery disease of the LMCA, LAD, LCx, or RCA.
2. Resting hemodynamics revealed no evidence of systemic
arterial
systolic or diastolic hypertension. There was no transvalvular
gradient
upon pullback of the catheter from the left ventricle to the
aorta.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function.
Brief Hospital Course:
43F with no prior cardiac history presenting with vague
esophageal symptoms and a slightly positive troponins.
# Positive cardiac enzymes: The patient ruled-in by troponin at
the OSH and continued to have slightly elevated troponins of
0.11 here; no ECG changes noted. CKs are within normal limits.
He was transferred here to undergo cardiac catheterization which
showed no angiographically apparent flow limiting epicardial
coronary artery disease of the LMCA, LAD, LCx, or RCA. The
slightly positive troponins are unlikely to represent cardiac
ischemia given his clean coronary arteries on cath. He does not
have LVH or kidney disease which are other reasons why he could
have slightly elevated trops. His elevations may also be seen
in PE/myocarditis/pericarditis; these also appear unlikely in
this patient. After his cath showed no CAD the ASA, plavix, and
heparin gtt he had been transferred on were stopped.
# PUMP: The patient appeared to be euvolemic. He underwent a
TTE which showed an EF > 55% and normal regional and global
biventricular systolic function. No pathologic valvular
abnormality was seen.
# RHYTHM: The patient was in normal sinus rhythm during this
hospitalization and was monitored on telemetry.
# DYSPHAGIA/GERD: The patient describes symptoms which seems to
be related to GERD and possibly of esophageal origin. He was
started on nexium 40 mg [**Hospital1 **] and was asked to follow up with GI
as an outpatient.
# EOSINOPHILIA: Mild with absoluate count of ~1000. Unclear
etiology. [**Month (only) 116**] be related to possible eosinophilic esophagitis
given his GI symptoms.
Medications on Admission:
1. Omeprazole 20mg daily
2. Advair diskus (uses before exercise)
Discharge Medications:
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Chest Pain
Secondary Diagnosis: Gastroesophageal Reflux
Discharge Condition:
Stable, chest pain free
Discharge Instructions:
You were admitted for chest discomfort. Based on your elevated
cardiac lab tests, we felt that you likely may have had a small
heart attack. You had a cardiac catheterization which did not
show any significant disease in your heart vessels. No
intervention was done. This all may have been from some
inflammation in the heart muscle or in the sac that surrounds
the heart. Also, the chest discomfort could have been from your
reflux disease.
You were started on 40 mg of nexium twice daily. Please keep
all followup appointments.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: worsening chest pains, shortness
of breath, bleeding from the groin site, numbness or tingling in
the legs.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 50679**]) to schedule a
followup appointment in [**12-26**] weeks.
Completed by:[**2108-11-1**]
|
[
"288.3",
"786.59",
"790.99",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
8398, 8404
|
6469, 6592
|
365, 391
|
8523, 8549
|
4076, 6362
|
9338, 9538
|
3055, 3229
|
8210, 8375
|
8425, 8425
|
8121, 8187
|
6379, 6446
|
8573, 9315
|
3244, 4057
|
2717, 2765
|
6610, 8095
|
277, 327
|
419, 2602
|
8476, 8502
|
8444, 8455
|
2796, 2919
|
2624, 2697
|
2935, 3039
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,629
| 193,099
|
47128
|
Discharge summary
|
report
|
Admission Date: [**2171-2-9**] Discharge Date: [**2171-2-10**]
Date of Birth: [**2111-12-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
upper GI bleed, gram negative bacteremia, spontaneous bacterial
peritonitis
Major Surgical or Invasive Procedure:
Femoral line placement, arterial line placement
History of Present Illness:
59 year old female with HCV cirrhosis, known grade I varices
presented to [**Hospital 1474**] Hospital [**2171-2-8**] after being found
lethargic at home by neighbors, incontinent of urine and feces.
She was admitted to the ICU, where she was found to have SBP
(900 WBCs with 97% PMN in peritoneal fluid), GNR in blood
cultures and HCT 21 from baseline 32 in [**12-15**]. Initially coffee
grounds were suctioned per NGT, then intermittent bright red
blood. Also noted to have melanotic stools. She was started on
octreotide gtt and protonix IV. She received 6 units of PRBC, 8
u FFP, IV Vitamin K, and DDAVP X 2. Last HCT 28, INR 1.6. She
was also found to be in anuric renal failure (Cr 2.5 from
0.6-0.8 in [**12-15**]). She was started on ceftriaxone and linezolid
(given h/o VRE) for SBP and transferred to [**Hospital1 18**] for further
management.
Past Medical History:
1) End stage liver disease: on transplant list
2) HCV genotype 1a cirrhosis
3) h/o SBP
4) h/o VRE UTI
5) Anemia
6) Type II diabetes
7) s/p cholecystectomy
8) s/p partial colectomy for diverticulosis
9) depression
10) Hypertension
11) Cervical cancer
Social History:
No IVDU. History of blood transfusion in [**2126**] for C-section.
Married with 2 children.
Family History:
Noncontributory
Physical Exam:
T 96.3, HR 110, bp 114/46, resp 25, 96% on 100% NRB
Gen: confused, moaning to questions, moderate respiratory
distress
Neck: JVD to angle of jaw
Pulm: diffuse ronchi and wheezing
Cardiac: distant heart sounds, tachycardic, regular, no M/R
appreciated
Abd: Edema of abdominal wall, distended, (+) ascites, hypoactive
bowel sounds
Ext: 2+ edema
Neuro: (+) asterixis.
Pertinent Results:
[**2171-2-9**] 11:18PM GLUCOSE-169* UREA N-89* CREAT-2.1*#
SODIUM-141 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2171-2-9**] 11:18PM ALT(SGPT)-56* AST(SGOT)-174* LD(LDH)-488* ALK
PHOS-164* AMYLASE-59 TOT BILI-13.6*
[**2171-2-9**] 11:18PM LIPASE-52
[**2171-2-9**] 11:18PM CALCIUM-8.1* PHOSPHATE-5.5* MAGNESIUM-2.0
[**2171-2-9**] 11:18PM OSMOLAL-331*
[**2171-2-9**] 11:18PM WBC-19.1*# RBC-2.92* HGB-9.9* HCT-29.0*
MCV-99*# MCH-33.8* MCHC-34.1 RDW-25.7*
[**2171-2-9**] 11:18PM PLT COUNT-62*
[**2171-2-9**] 11:18PM PT-16.6* PTT-34.5 INR(PT)-1.7
[**2171-2-9**] 11:18PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2171-2-9**] 11:18PM URINE BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-LG UROBILNGN-4* PH-5.0 LEUK-SM
[**2171-2-9**] 11:18PM URINE RBC-21-50* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**12-1**] TRANS EPI-0-2 RENAL EPI-0-2
[**2171-2-9**] 11:18PM URINE HYALINE-21-50
OSH
Abd/pelvis CT: liver appearance c/w cirrhosis; ascites
Head CT: (-) for acute pathology
Brief Hospital Course:
59 year old female with [**Hospital 13808**] transferred to [**Hospital1 18**] ICU with GN
bacteremia, GI bleed, and respiratory distress. She was covered
broadly with antibiotics (ceftriaxone, levofloxacin, and
linezolid) for GN bacteremia/SBP. Her respiratory distress noted
on admission was most likely secondary to volume overload in the
setting of aggressive fluid resuscitation and oliguric renal
failure (likely secondary to ATN vs hepatorenal syndrome). She
was started on a trial of CPAP and received large doses of Lasix
to attempt to remove fluid with minimal response. On [**2171-2-10**]
a.m., she vomited bright red blood while wearing CPAP mask,
aspirating a large amount, with resultant desaturation into the
70s. As a result she was emergently intubated. She underwent an
upper endoscopy on [**2171-2-10**] which showed grade I esophageal
varices without bleeding, portal gastropathy with diffuse
oozing, and oozing of blood in the duodenum without definitive
ulcer. She received 3 units of FFP, 1 unit of platelets, and 1 u
PRBC and was continued on Protonix and octreotide drip. During
placement of a right subclavian central venous line [**2171-2-10**], the
patient developed a tension pneumothorax that required chest
tube placement. Given progressive volume overload and metabolic
acidosis, the renal service was consulted, and CVVHD initiated.
However, the patient became hypotensive (likely sepsis +
hypovolemia in setting of GI bleed) which was refractory to
stress dose steroids and multiple pressors (norepinephrine,
dopamine, Neo-Synephrine, vasopressin). She also developed a
progressive metabolic acidosis despite IV bicarbonate
effusion/CVVHD. Following discussion with the patient's family
regarding the patient's grave prognosis, the patient was made
CMO and pressors were withdrawn. Shortly thereafter, the patient
progressed to asystole. The ventilator was shut off. The
patient's pupils were fixed and dilated and she was unresponsive
to painful stimuli. There were no spontaneous respirations or
heart sounds auscultated over a 5 minute period. Time of death
[**2171-2-10**] 6:25 p.m. The family was present at time of death and
declined autopsy. Given admission time <24 hours, the medical
examiner was notified who declined autopsy.
Medications on Admission:
Medications on Transfer
Ceftriaxone 1 g IV q24h
Linezolid 600 mg IV q12h
Lactulose 30 ml PO QID
Multivitamin
Folate
Thiamine
Morphine 2 mg IV q6h prn
Protonix gtt
octreotide gtt
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: cardiac arrest
Secondar: End stage liver disease, hepatitis C, cirrhosis,
spontaneous bacterial peritonitis, gram negative bacteremia,
acute renal failure, upper gastrointestinal bleed
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
Completed by:[**2171-4-17**]
|
[
"571.5",
"578.9",
"518.81",
"584.9",
"995.92",
"038.9",
"785.52",
"512.8",
"572.2",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"99.04",
"96.04",
"96.71",
"45.13",
"34.04",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
5674, 5683
|
3174, 5446
|
362, 411
|
5920, 5930
|
2108, 3117
|
5987, 6026
|
1691, 1708
|
5704, 5899
|
5472, 5651
|
5954, 5964
|
1723, 2089
|
247, 324
|
439, 1293
|
3126, 3151
|
1315, 1566
|
1582, 1675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,186
| 117,342
|
33479
|
Discharge summary
|
report
|
Admission Date: [**2118-4-7**] Discharge Date: [**2118-4-18**]
Date of Birth: [**2039-8-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
off-pump CABG x 3(LIMA>LAD, SVG>PDA>OM) [**4-13**]
History of Present Illness:
This is a 78 year-old male with a history of paroxysmal atrial
fibrillation on coumadin, hypertension, mitral regurgitation,
and vasculopathy including peripheral vascular disease, carotid
artery disease, and CAD who presents for evaluation of chest
pain, transferred to the [**Hospital1 18**] ED from OSH for evaluation. He
has only been seen here once in the cardiology department. The
patient explains that he was carrying a case of pepsi and water
from the store when he experienced substernal chest pressure
along with SOB. The chest pain and SOB intermittently continued
until he was given SL nitro at the OSH which relieved the chest
pain within minutes. He explains that he has never had CP or SOB
that he can remember. He denied any radiation, N/V, or
diaphoresis. First set of CEs at the OSH were negative and he
was started on a nitro gtt for unclear reasons. He was also
given ASA, Plavix, and Lasix. He was chest pain free after just
one SL nitro. He was sent to [**Hospital1 18**] ED for further evaluation.
Of note, pt is a very poor historian. He cannot remember if he
has had a stress test in the past or a cath. He does not know
his medications. Per recent cardiology note, has known
infero-apical disease. He is quite active and has not noticed
any symptoms with the scrap metal work that he does.
In the ED, initial vitals were T: 98 HR: 82 BP: 147/55 RR: 18
O2Sat: 100%2L. He was transferred from OSH on nitro gtt to
control his CP. He was given ASA 325 and Plavix 300 at the OSH.
He was also given Lasix at the OSH. Patient received SL nitro
the OSH and was admitted for further evaluation and management.
Of note, pt has had hearing loss in the left ear for the past
six days. He saw an ENT (Dr. [**Last Name (STitle) 77638**] who started a course
of Bactrim and prednisone. Pt reports that he "always gets ear
infections."
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 dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
? CAD
AAA s/p repair
Left BKA
HTN
Hyperlipidemia
PVD
abnormal exercise treadmill test with inferoapical defect per
[**2-12**] cards note
? gout
? steroid therapy
Social History:
Social history is significant for the absence of current tobacco
use. Pt admits to heavy smoking history, quit about 4 years ago.
Smoked for 60 years, 2.5 ppd. No current alcohol but reports
that he used to drink 4-6 beers/night.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T 97.9 HR 68 BP 142/54 RR 16 96%RA
Gen: WD/WN elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, no JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Grade II/VII systolic murmur. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged
by palpation. No abdominial bruits. Normoactive BS.
Ext: No c/c/e. No femoral bruits. s/p left BKA. RLE pulses
intact but diminished.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2118-4-18**] 05:30AM BLOOD WBC-6.9 RBC-2.80* Hgb-8.6* Hct-25.3*
MCV-91 MCH-30.8 MCHC-34.0 RDW-14.6 Plt Ct-181
[**2118-4-18**] 05:30AM BLOOD PT-22.2* PTT-31.6 INR(PT)-2.1*
[**2118-4-17**] 05:47AM BLOOD PT-19.1* PTT-30.5 INR(PT)-1.8*
[**2118-4-16**] 06:00AM BLOOD PT-15.8* PTT-55.1* INR(PT)-1.4*
[**2118-4-18**] 05:30AM BLOOD Glucose-104 UreaN-37* Creat-1.5* Na-138
K-3.9 Cl-105 HCO3-23 AnGap-14
[**2118-4-17**] 05:47AM BLOOD Glucose-120* UreaN-39* Creat-1.6* Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
[**2118-4-7**] 05:39PM BLOOD Glucose-146* UreaN-35* Creat-2.6* Na-139
K-4.6 Cl-107 HCO3-22 AnGap-15
CHEST (PA & LAT) [**2118-4-16**] 2:57 PM
CHEST (PA & LAT)
Reason: asses for pnuemo
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with s/p chest tube removal
REASON FOR THIS EXAMINATION:
asses for pnuemo
PA AND LATERAL CHEST, [**4-16**].
HISTORY: Chest tube removed. Assess for pneumothorax.
IMPRESSION: PA and lateral chest compared to [**2118-4-15**]:
Lung volumes have improved, though there is still significant
bibasilar and subsegmental atelectasis. Tiny if any left apical
pneumothorax is present, and there is no appreciable left
pleural effusion. Small right pleural effusion is stable.
Cardiomediastinal silhouette has a normal postoperative
appearance. Right jugular line ends in the upper SVC.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 77639**] (Complete)
Done [**2118-4-13**] at 12:06:31 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2039-8-21**]
Age (years): 78 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Congenital heart
disease. Left ventricular function. Mitral valve disease.
Valvular heart disease.
ICD-9 Codes: 745.5, 440.0, 396.9
Test Information
Date/Time: [**2118-4-13**] at 12:06 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW06-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Findings
LEFT ATRIUM: Normal LA size. 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. All four pulmonary veins identified and enter
the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No AS. Mild (1+) AR. Eccentric AR jet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits).
Transient anterior and anteroseptal wall motion abnormality with
application of myocardial stabilizers and lifting of heart for
distal coronary anastomoses.
Brief Hospital Course:
He wzs maintained on a heparin drip for NSTEMI and atrial
fibrillation. Cardiac catheterization showed LM and 3VD. He was
evaluated by ENT and was noted to have 80% loss on the right
side. He was also diagnosed with a mild ear infection on the
left. He continued on ear drops and prednisone for this.
Outpatient MRI recommended by ENT can be deferred until after
CABG. His creatinine peaked at 3.0, but improved to 1.6 prior to
surgery.
He was taken to the operating room on [**2118-4-13**] where he
underwent an off pump CABG x 3. He remained intubated overnight
for significant chest tube output but was extubated the morning
of POD #1. He was transferred to the floor on POD #2.
He was restarted on coumadin for chronic afib. His chest tubes
and wires were pulled without incident. He did well
postoperatively and he was ready for discharge to rehab on POD
#5.
Medications on Admission:
Zestril 40 mg PO daily
Pletal 100 mg PO daily
Hydralazine 10 mg PO BID
Labetolol 200 mg PO BID
Gemfibrozil 600 mg PO BID
Pravastatin 40 mg daily
Nifedipine CR 60 mg SR [**Hospital1 **]
Allopurinol 100 mg PO daily
Coumadin 2.5 mg PO daily
Bactrim DS 160/800 one tablet [**Hospital1 **]
Prednisone 10 mg PO TID
MVI
Terasozin 2 mg QHS
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO daily ().
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Check INR [**4-20**], goal INR [**1-9**] for atrail fibrillation.
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: then reassess need for diuresis.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 5 days: with lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
CAD now s/p CABG
PMH: AAA s/p repair, Left BKA, HTN, Hyperlipidemia, PVD, gout, L
perforated ear drum on prednisone until [**4-15**]
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 11493**] 2 weeks
Dr. [**Last Name (STitle) 17863**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Already scheduled appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2118-7-13**] 8:40
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2118-4-18**]
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6,564
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13874
|
Discharge summary
|
report
|
Admission Date: [**2185-5-18**] Discharge Date: [**2185-5-20**]
Date of Birth: [**2135-5-17**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Compazine / Morphine / Toradol
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain and R flank pain
Major Surgical or Invasive Procedure:
aspirin desensitization
cardiac catheterization
History of Present Illness:
50 yo M with history of HTN, CAD, CHF with EF of 30%, s/p ICD
pacemaker in [**2182-1-29**] for VT, and biploar, who presents with
chest pain and R lower flank pain. Pt was admitted for similar
sx's in [**3-5**]. Pt states on the morning of admission at about 9
a.m. he developed R flank pain. States he had intense pain on
urination and noticed that his urine had blood in it. States the
pain has been constant since it began and was only partially
relieved by IV dilaudid which he received in the ED. States it
is sharp in nature and is equally as strong if he lies still vs.
moving around.
.
Pt states around 12:30p.m. on the DOA he also developed chest
pain while he was sitting watching t.v. States it was an [**9-7**]
located in the center of his chest and radiated to his L jaw, L
neck, and L arm. States he also had SOB, nausea, and
diaphoresis. Took 2 SL nitro's and the pain decreased to a [**5-8**].
He presented to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and was subsequently transferred
to the [**Hospital1 **] for cath. However, given his history of allergy to
aspirin (states he gets SOB and his whole body swells) he was
transferred to the CCU for asa desensitization prior to cath.
On ROS pt denies any recent vomiting, diarrhea, BRBPR, melena.
No fevers, chills, night sweats or changes in weight. States
legs occasionally get swollen but this has not occurred lately.
States at baseline he can only walk a short distance before
getting SOB. Sleeps on one pillow and denies any PND or
orthopnea.
.
On review of the online records from the [**Hospital1 **], [**Location (un) 620**] and Mt.
[**Location (un) **], it was found that the patient has had 4 admissions in
the past 4 months for these exact same sx's. Each admission
makes note of a completely negative workup including negative
cardiac enzymes, no ECG changes, and CT scans which show no
evidence of nephrolithiasis. His last [**Hospital1 **] admission documents
malingering in which the patient was found cutting his hand and
placing drops of blood in his urine and then denying this act
later. All four admissions document his IV dilaudid seeking
behavior, and in the most recent admission to [**Hospital3 **] on
[**2185-4-29**], he left AMA after he was refused IV dilaudid and offered
only po or IM.
Past Medical History:
PAST MEDICAL HISTORY:
1. CAD. M.I. x 2 ([**2182**], [**2183**]). Catherization @ [**Hospital1 336**] [**2185-2-17**].
LAD proximal 40% lesion, mid 30% lesion. DIAG1 proximal 50%
lesion. mid 40% lesion. LCA CX proximal diffuse 50% lesion.
RCA ostial 30% lesion. Conclusion. Moderate non-obstructive
cornary disease. ECHO [**5-2**] at [**Hospital1 **]. Enlarged LV
with hypokinesia of inferoseptal wall. EF 40% enlarged LA.
Trileaflet aortic valve. Enlarged aortic root [**3-2**] HTN. Stress
test [**5-2**] at [**Hospital1 **]. Dipyridamole injection. Normal
uptake of radioisotope without perfusion defect. EF 34%.
2. Dyslipidemia. Cholesterol panel [**2185-6-11**]. trig 312. HCL 37.
LDL cal. 18.
3. History of hypertension.
4. Syncope. Hospitalization [**5-/2182**] @ [**Hospital1 18**] for an episode of
syncope and palpitations.
5. Status post ICD pacemaker implantation for VT in [**2182-1-29**]
@ [**Hospital1 336**]
6. Nephrolithiasis [**2183**]
7. Status post cholecystectomy.
8. Chronic back pain due to degenerative disc disease. Seen on
CT at L4-5 and S1 [**10-2**]
9. Bipolar diagnosed [**2183**].
10. multiple hospitalizations [**2182**]-[**2185**] around the area for
chest pain, flank pain, hematuria.
11. PE in [**3-5**] at [**Hospital1 **], treated with coumadin, then pt reports
he had a filter placed at [**Hospital **] hospital in [**4-2**] and since has
not been taking coumadin.
Social History:
On admission pt stated he currently lives with his wife their
two children, a 17 year-old daughter and a 15 year-old son, with
her. However, later he disclosed that his wife left him for
another man in [**2-2**] and took their children with her. States he
lives alone and has little social support. He used to work as a
commercial fisherman and as licensed auto mechanic, however he
stopped working in [**2182**] s/p his ICD pacemaker placement. Last
year he started receiving disability benefits. He is on Mass
Health.Patient??????s diet consists primarily of meat and potatoes.
He is unable to exercise because of his back pain. He has a 15
pack-year smoking history, but recently stopped 4 months ago.
He denies alcohol use but admitted to the social worker that he
used to drink heavily and occasionally attends AA meetings. He
used pot in high school, but denies any additional recreational
drug use.
Family History:
Family history is significant for heart disease. Father died
from an M.I. at 70 years old. [**Name (NI) **] brother has heart
problems. Aunts on his father??????s side have unstable angina.
Mother died at 62 years old from breast CA, which metastasized
to the bone. There is no family history of clotting disorders.
Physical Exam:
98.4 91 111/73 15 97% 2L NC
Gen: repetitively complaining of pain, but easily moves in bed
and appears comfortable.
HEENT: MMM, OP clear
Neck: no stiffness or limited ROM
CV: RRR, no m/r/g
Lungs: CTAB
Abd: s/nt/nd, +bs.
Back: + R CVA tenderness.
Ext: no c/c/e. DP and PT pulses 2+ bilaterally.
Neuro: A&Ox3.
Pertinent Results:
[**2185-5-18**] 05:28PM GLUCOSE-101 UREA N-33* CREAT-1.2 SODIUM-143
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14
[**2185-5-18**] 05:28PM CK(CPK)-46
[**2185-5-18**] 05:28PM CK-MB-NotDone cTropnT-<0.01
[**2185-5-18**] 05:28PM CALCIUM-9.3 PHOSPHATE-4.0 MAGNESIUM-2.1
[**2185-5-18**] 05:28PM VALPROATE-20*
[**2185-5-18**] 05:28PM WBC-7.5 RBC-4.55* HGB-13.1* HCT-38.1* MCV-84#
MCH-28.9 MCHC-34.5 RDW-14.6
[**2185-5-18**] 05:28PM PLT COUNT-279#
[**2185-5-18**] 05:28PM PT-13.6 PTT-35.2* INR(PT)-1.2
[**2185-5-18**] 05:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2185-5-18**] 05:28PM URINE MUCOUS-OCC
[**2185-5-18**] 05:28PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
CXR: No acute cardiopulmonary process identified.
ECG:
NSR at 98. LAD. nl intervals. possible small ST depressions in
V4-5 compared to prior (although on review of multiple old ECG's
this appears to have been present in the past).
Stress Test ([**2185-5-19**]): This 50 yo man (s/p MI and h/o VT with
ICD implantation in [**2182**]; non-obstructive CAD with LVEF ~30% on
cardiac catheterization in [**2185**]) was referred for a CAD
evaluation. The patient was administered 0.142 mg/kg/min of IV
persantine over 4 minutes. No neck, back, arm or chest
discomfort was reported by the patient throughout the procedure.
No significant ST segment changes were noted from baseline. The
rhythm was sinus with one VPD. The hemodynamic response to
infusion was appropriate. Post MIBI injection, the patient was
administered 125mg of IV Aminophylline.
IMPRESSION: No anginal type symptoms or ischemic EKG changes
from
baseline.
pMIBI ([**2185-5-19**]): Diffuse global hypokinesis, LVEF 36%. No
reversible perfusion defects detected. Mild fixed inferior wall
defect.
CT abdomen ([**2185-5-19**]):
1) No evidence of nephrolithiasis or secondary signs to suggest
obstruction.
2) Diffuse coronary artery calcification.
3) Infrarenal IVC filter.
4) Status post cholecystectomy.
Brief Hospital Course:
A/P: 50 yo M with history of HTN, CAD, CHF with EF of 30%, s/p
ICD pacemaker in [**2182-1-29**] for VT, and biploar, who presents with
chest pain and R lower flank pain. This is at least the pt's 4th
admission for these two symptoms in the past 4 months; all of
these admissions have resulted in negative workups and all have
been dominated by the pt's IV dilaudid-seeking behavior.
.
#Cardiac:
1. CAD: The pt's description of chest pain was concerning for
ACS, however, since the pt had presented at least 4 times in the
past 4 months with this exact same description and on this
admission he had negative enzymes with no ECG changes, it was
considered unlikely that this pain was cardiac. The 1mm ST
depressions seen in V4-5 have been present in the past on some
ECG's. Thus, it was determined that a catheterization was not
necessary. The pt underwent a pMIBI stress test which showed no
reversible perfusion defects. The pt was continued on plavix, BB
and was started on an ACEi. He also underwent aspirin
desensitization successfully and was started on ASA 325 daily.
His atorvastatin was increased to 80mg daily given his CAD and
multiple risk factors.
.
2. Pump: The pt's BP remained in good range with metoprolol and
lisinopril. His blood pressure will be monitored by his new PCP
and medication titration can occur as an outpt.
.
3. Rhythm: telemetry monitoring showed no events. Has h/o
ICD/pacer.
.
#Pulm: has h/o PE now s/p IVC filter placement. His O2 sats
remained good while in house.
.
#R flank pain with questionable hematuria: pt gives h/o
nephrolithiasis, however, has had 4 CT's in the past 4 months
which have all been negative. Pt was observed during last
admission to have cut his hand and squeezed the blood into his
urine cup. His Ua on this admission was negative for blood. He
underwent a CT which showed no evidence of nephrolithiasis or
secondary signs to suggest obstruction. His Cr on admission was
1.2 and subsequently increased to 1.9, however, the pt appeared
dry and his UOP was low. He was hydrated with IVF and repeat Cr
was 1.1. Urology signed off and stated there were no GU issues.
However, the pt continued to complain of R flank pain and stated
that he had been having this pain for several months and the
only thing that had ever helped it was IV dilaudid. When he was
told that he would not be receiving IV dilaudid he stated that
he was ready to go home and insisted on speedy arrangements of
transportation.
.
#Psych/bipolar disorder: Pt was continued on depakote,
trazodone, and zoloft. He was seen by social work who provided
support given that his wife recently left him, leaving him alone
in his apartment. He denied any suicidal ideations and was
deemed safe for discharge. He was urged to follow up with his
outpatient psychiatrist as soon as possible.
.
#Pain: pt reported severe pain, but was able to move very
easily. He stated he had [**9-7**] pain in his R flank that was worse
with ambulation, however, he was repeatedly seen wandering the
halls in search of food in the patient kitchen. He was treated
with his outpatient dose of Oxycontin 80mg [**Hospital1 **] and was given IM
and po dilaudid 1mg q6 hours prn. On discharge he requested
vicodin, stating that he was trying to get off of his oxycontin.
This medication was declined and the pt was urged to find a PCP
who could assist him with getting off of his oxycontin gradually
over time after they have arranged a contract verifying that the
pt will not pursue other narcotics from other providers.
Medications on Admission:
Trazodone 100 mg PO qhs
Sertraline (Zoloft) 200mg PO daily
Toprolol (Metoprolol XL) 200 mg PO daily
Verapamil SR 240 mg PO daily
Depakote (divalproex sodium) 750 mg PO qpm. 500 mg PO qam
oxycontin 80mg PO bid
plavix 75mg PO daily
SL nitro prn
Discharge Medications:
1. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: Two
(2) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
2. Trazodone HCl 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO QAM (once a day (in
the morning)).
7. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig:
Three (3) Tablet, Delayed Release (E.C.) PO QPM (once a day (in
the evening)).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
non-cardiac chest pain
Discharge Condition:
stable
Discharge Instructions:
Please make an appointment and find a new PCP as soon as
possible. Given the results of your tests, your chest pain is
not likely cardiac in nature and so going from hospital to
hospital with this complaint is more likely to put you at
increased danger due to unnecessary tests. Similarly, there is
no evidence of kidney stones so pursuing more imaging tests
would not likely be useful. What is most likely to help is to
find a PCP and address your concerns with this doctor who will
follow you over the long-term.
Followup Instructions:
Please find a PCP [**Name Initial (PRE) 2678**]. If you continue to have right flank pain
or hematuria, please address this with your PCP and avoid having
additional CT scans.
If you are unable to find a PCP, [**Name10 (NameIs) **] call [**Hospital **] at [**Telephone/Fax (1) 250**] to schedule an appointment first
available.
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"414.01",
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"V45.01",
"584.9",
"786.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
12975, 12981
|
7831, 11347
|
327, 376
|
13047, 13055
|
5771, 7808
|
13618, 13948
|
5106, 5427
|
11642, 12952
|
13002, 13026
|
11373, 11619
|
13079, 13595
|
5442, 5752
|
260, 289
|
404, 2715
|
2759, 4163
|
4179, 5090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,988
| 136,757
|
33593
|
Discharge summary
|
report
|
Admission Date: [**2104-3-31**] Discharge Date: [**2104-4-5**]
Date of Birth: [**2029-5-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
right sided lip numbness, indigestion
Major Surgical or Invasive Procedure:
[**3-31**] CABG x 3 (LIMA -> LAD, SVG -> OM, SVG -> RCA)
History of Present Illness:
74 yo F who presented to [**Hospital3 3583**] ED with right sided lip
numbness. MRI and TEE neg by report. Dc'd home and outpatient
stress test done with EKG changes. Cath showed 3 VD. Referred
for surgery.
Past Medical History:
Emphysema, Osteoporosis, Stage I breast cancer s/p right
lumpectomy ALND + XRT [**2090**], Bursitis, Melanoma s/p excision,
Diverticulosis, h/o MRSA, Tonsillectomy, D&C, 4 polyps removal c
colonoscopy
Social History:
retired
tobacco: < 1 ppd x 50 years, quit [**7-5**]
etoh: 4 glasses of wine per week.
Family History:
history of stroke and MI in [**6-6**] siblings
Physical Exam:
HR 66 RR 16 BP 150/77
NAD
Lungs CTAB
Heart RRR
Abdomen benign
Some varicosed veins
Pertinent Results:
[**2104-4-5**] 07:05AM BLOOD
WBC-5.6 RBC-2.64* Hgb-8.6* Hct-25.5* MCV-97 MCH-32.6* MCHC-33.8
RDW-13.4 Plt Ct-340
[**2104-4-5**] 07:05AM BLOOD
Glucose-98 UreaN-9 Creat-0.5 Na-142 K-4.5 Cl-105 HCO3-30
AnGap-12
CHEST (PA & LAT) [**2104-4-3**] 1:52 PM
CHEST PA AND LATERAL: There are bilateral pleural effusions and
atelectatic changes. There is slight enlargement of the heart
and slight widening of the mediastinum. The right IJ is in the
lower SVC. No pneumothorax is detected. There is no evidence of
pneumonia.
IMPRESSION: Bilateral pleural effusions and atelectatic change,
slight enlargement of the heart and mediastinum, all grossly
unchanged, all consistent with post-operative change.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
[**Hospital1 **] - Ascending: *3.5 cm <= 3.4 cm
[**Hospital1 **] - Descending Thoracic: 2.3 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Hospital1 **]: Normal ascending [**Hospital1 5236**] diameter. Complex (>4mm) atheroma
in the aortic arch. Complex (>4mm) atheroma in the descending
thoracic [**Hospital1 5236**].
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**1-30**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusion
Pre-CPB: LV shows good systolic fxn, with mild HK of the
anterior septum. No spontaneous echo contrast is seen in the
left atrial appendage. Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm) atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic [**Month/Day (2) 5236**]. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-30**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB: Patient is AV paced, on an infusion of NTG.
Preserved biventricular systolic fx. No AI, trace MR. [**First Name (Titles) **] [**Last Name (Titles) 18350**]t.
Brief Hospital Course:
She was taken to the operating room on [**3-31**] where she underwent a
CABG x 3. She was transferred to the ICU in stable condition on
neo and propofol. She was extubated later that same day. She was
transferred to the floor on POD #1. She did well
postoperatively. She was started on keflex for some erythema
surrounding her sternal incision. Chest tubes / foley / PW out
with out sequele. PT consult. Pt stable for home
Medications on Admission:
Actonel 35 [**Last Name (LF) 77843**], [**First Name3 (LF) **] 325', Vit D 400'
Discharge Medications:
1. [**Last Name (un) 1724**]
Actonel 35 [**Last Name (LF) 77843**], [**First Name3 (LF) **] 325', Vit D 400'
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. 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*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD s/p CABG
PMH: Emphysema, Osteoporosis, Stage I breast cancer s/p right
lumpectomy ALND + XRT [**2090**], Bursitis, Melanoma s/p excision,
Diverticulosis, h/o MRSA, Tonsillectomy, D&C, 4 polyps removal c
colonoscopy
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or p
Followup Instructions:
Dr. [**First Name (STitle) 27598**] 2 weeks
Dr. [**Last Name (STitle) 5310**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2104-4-5**]
|
[
"272.4",
"V12.79",
"V15.3",
"V17.3",
"458.29",
"414.01",
"401.9",
"V17.1",
"V15.82",
"492.8",
"V10.82",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5755, 5806
|
4046, 4470
|
311, 370
|
6069, 6079
|
1115, 4023
|
6286, 6440
|
949, 997
|
4600, 5732
|
5827, 6048
|
4496, 4577
|
6103, 6263
|
1012, 1096
|
234, 273
|
398, 606
|
628, 830
|
846, 933
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,688
| 136,641
|
49309
|
Discharge summary
|
report
|
Admission Date: [**2140-10-23**] Discharge Date: [**2140-10-27**]
Date of Birth: [**2060-6-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None at [**Hospital1 69**]
Two bowel resections for cecal volvulus performed at an outside
hospital prior to transfer. Intubation x 2.
History of Present Illness:
Mr. [**Known lastname **] is a 80 yo M with HTN, HL, and PAF on coumadin who
was originally admitted to OSH on [**2140-10-3**] for abdominal pain.
He was found to have a partial small bowel obstruction and was
taken to the OR the following day. He was found to have a cecal
volvulus, which was detorsed and he underwent ileocolectomy with
primary anastomosis of the ileum to the ascending colon. He then
went into afib, requiring dilt gtt, and transferred to the ICU.
At the same time, he was noted to have a worsening ileus and was
taken back to the OR on [**10-12**]. He was found to have dense
adhesions with a kink just proximal to anastomsosis, and he had
a ileo-to-transverse colon anastomosis. The pathology specimens
from both resection showed mucosal ischemic necrosis of the
resection margins. Wound cultures grew ESBL E. coli and
enterococcus for which he was being treated with
ertapenam->meropenam. He had a CTA of the abdomen which showed
good flow in the proximal superior mesenteric artery and flow in
the inferior mesenteric artery and celiac axis.
Immediately postoperatively, pt went into afib with RVR, was
started on dilt and neo gtts, and underwent DC cardioversion.
Reportedly, he has not tolerated CCB or BBs in the past because
of near sycnope and sig. bradycardia (cardiology Dr. [**Last Name (STitle) 13310**].
He was extubated postoperative day 1 but needed to be
reintubated postop day 6 for hypercapnia. He spiked a fever
about 36 hours ago, was found to have a RUL pneumonia. Sputum
grew pseudomonas and pt was treated with ertapenam->meropenam.
Pt was extubated yesterday and placed on BiPap.
He was noted to be back in afib, Cardiology was consulted, and
he was started on metoprolol and amiodarone.
Pt's family is requesting transfer.
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:
Hyperlipidemia
Hypertension
Atrial fibrillation
Social History:
He quit smoking in [**2090**] after 60 pack years. He drinks 2-4
alcoholic drinks. Independent prior to hospitalization
Family History:
N/C
Physical Exam:
VITAL SIGNS:
T 96.2 BP 126/71 P 98 RR 18 O2sat 98%2LNC
GENERAL: Pleasant, well appearing elderly man, in NAD, AAOx3
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Irregularly irregulr. S1, S2. No murmurs, rubs or
[**Last Name (un) 549**].
LUNGS: transmitted upper airway sounds, no wheezing/rales
ABDOMEN: NABS. Soft, NT, distended, midline surgical scar c/d/i
covered with steristrips. 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.
Pertinent Results:
ADMISSION LABS [**2140-10-23**]:
BLOOD
WBC-13.4* Hgb-9.9* Hct-30.6* Plt Ct-505*#
Neuts-91.1* Lymphs-4.9* Monos-2.2 Eos-1.4 Baso-0.4
PT-12.9 PTT-40.0* INR(PT)-1.1
Glucose-91 UreaN-32* Creat-1.0 Na-142 K-5.4* Cl-101 HCO3-31
AnGap-15
ALT-23 AST-28 LD(LDH)-219 AlkPhos-240* TotBili-1.3
Albumin-5.1* Calcium-9.7 Phos-5.1* Mg-2.5
URINE
Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
RBC-135* WBC-19* Bacteri-FEW Yeast-NONE Epi-0 RenalEp-1
CastHy-20*
Mucous-RARE
Eos-POSITIVE
MICROBIOLOGY:
[**2140-10-23**] UCx: negative
[**2140-10-23**] BCx: no growth to date
[**2140-10-23**] MRSA screen: negative
[**2140-10-25**] Stool Cdiff: negative
STUDIES:
[**2140-10-23**] EKG:
Sinus rhythm. Left atrial abnormality. Right precordial/anterior
lead T wave abnormalities are non-specific but cannot exclude
myocardial ischemia. Clinical correlation is suggested. Since
the previous tracing of [**2134-11-1**] further right precordial lead T
wave changes are present.
[**2140-10-23**] CXR:
PICC terminates within the proximal superior vena cava. Cardiac
silhouette is mildly enlarged, and is accompanied by mild
pulmonary vascular engorgement. Moderate right pleural effusion
with adjacent right basilar atelectasis and/or consolidation is
new. Left hemidiaphragm appears indistinct, probably on the
basis of motion artifact, but small effusion or early
consolidation is not excluded.
DISCHARGE LABS [**2140-10-27**]:
WBC-10.3 Hgb-9.6* Hct-29.6* Plt Ct-606*
PT-19.3* PTT-61.5* INR(PT)-1.8*
Glucose-89 UreaN-28* Creat-0.8 Na-139 K-4.3 Cl-102 HCO3-28
AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] is an 80 yo M with HTN, HL, and PAF on coumadin who
was originally admitted to OSH on [**2140-10-3**] for abdominal pain,
found to have cecal volvus in OR, s/p bowel resection x2, course
complicated by afib with RVR requiring cardioversion.
# Pseudomonas PNA: The patient was found to have a RUL PNA,
sputum Cx positive for Psuedomonas at the outside hospital. He
was started on Meropenem for an 8 day course, to end [**2140-10-29**]. He
has been afebrile during this hospitalization, and his WBC count
has trended down from 14 -> 10.3 on discharge.
# ESBL E. coli wound infection: The patient was found to have
ESBL E. coli in his wound culture from the outside hospital. He
has been treated with Meropenem, which is to be continued until
[**2140-10-29**]. As above, he has been afebrile and WBC has decreased.
He has had no abdominal pain during this hospitalization.
# Leukocytosis: Attributable to the 2 infections above. Urine Cx
and Blood Cx have been negative. Cdiff also negative. Pt has
been afebrile and stable during this hospitalization.
# Hypercapnic respiratory distress: The patient was intubated at
the outside hospital for hypercapnic respiratory distress. He
did not require intubation during this hospitalization. He
reports breathing comfortably and has been weaned down to 1L NC.
He is currently satting 95% on 1L NC. He also uses
albuterol/atrovent nebulizers prn, which have been helpful with
his breathing.
# Atrial fibrillation: The patient went into atrial fibrillation
post-operatively, which required DC cardioversion at the outside
hospital. The patient was started on Amiodarone 200mg PO daily
with good effect. CCB and beta blockers were avoided, as the
patient's cardiologist Dr. [**Last Name (STitle) 13310**] reported syncope and
significant bradycardia while on these medications. The patient
had one episode of bradycardia to the 40s on the day prior to
discharge, but was mentating well, BP 130s/60, and other vital
signs were stable. He has converted back into normal sinus
rhythm and has not had any other bradycardic events. HR has been
stable in the 60s. He should have PFTs, LFTs, and TFTs checked
as an outpatient, as he has just started amiodarone. The patient
is being anticoagulated with Coumadin and Heparin bridge.
Discharge INR 1.8. Please continue the Heparin drip until there
are 2 days of consecutive INR levels between [**1-26**].
# Loose stools: The patient had a flexiseal in place, which was
removed the day prior to discharge. He continues to have loose
stool, likely [**1-25**] to postoperative changes. Cdiff was negative.
# HTN: The patient was on Lisinopril 10mg PO daily as an
outpatient. This has been held during the hospitalization. BP
has ranged from 114/62-130/70, so Lisinopril will continued to
be held. There are no contraindications to restarting Lisinopril
as an outpatient if the patient has higher blood pressures in
the near future.
# Cecal volvulus: The patient is s/p bowel resections x2 at an
outside hospital. The staples were removed from the surgical
scar, and the wound has been clean. The lower side of the wound
has been draining. The incision has been covered with an
abdominal pad, which has been changed daily. The patient has not
had any abdominal pain and is tolerating a regular PO diet on
discharge.
# Oral herpes-like lesion: The patient was found to have a
herpetic oral lesion upon intubation at the outside hospital. He
was continued on Acyclovir at this hospital. Last day of
Acyclovir is [**2140-10-28**].
# Psych: The patient was transferred on Celexa and Seroquel.
Seroquel has been held, but the patient has been continued on
Celexa with good effect. The patient has been in good spirits
and highly motivated to get well. Please re-evaluate as an
outpatient regarding the necessity of this medications.
Medications on Admission:
Simvastatin 40 mg
ASA 81 mg
Coumadin
Lisinopril 10 mg daily
Vitamin D 1000 units daily
MVT
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 days: End [**2140-10-28**].
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob, wheeze.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
9. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 3 days: End [**2140-10-29**].
10. Heparin (Porcine) in NS 10 unit/mL Kit Sig: weight-based
dosing guidelines Intravenous continuous: until INR [**1-26**] for 2
consecutive days;
please see attached weight-based heparin dosing guidelines.
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
14. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
15. Outpatient Lab Work
Please check daily INR ([**1-26**]) until therapeutic for 2 consecutive
days.
Please check PTT as indicated by Heparin Dosing guidelines
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis
Pseudomonas Pneumonia
Atrial fibrillation
Extended Spectrum Beta Lactamase E. coli wound infection
Secondary Diagnosis
Cecal Volvulus
Herpetic Oral Lesion
Hypercapnic respiratory distress
Discharge Condition:
Stable, improved, O2sat 95% on 1L, heart rate 63 - normal sinus
rhythm
Discharge Instructions:
You were transferred to [**Hospital1 69**]
with pneumonia and a positive wound culture. You have been
treated with intravenous antibiotics, which need to be continued
until [**2140-10-29**]. You were also on an antiviral medication for a
lesion in your mouth, which will be continued until [**2140-10-28**]. You
were transferred from the intensive care unit to the medical
floor with no issues. Your breathing has improved, and you have
not required any intubation while you were at this hospital.
You were also in atrial fibrillation while you were in the
hospital. You were started on Amiodarone while you were at the
other hospital. Your heart rate has been well controlled, and
you are now back in a normal rhythm. Please follow up with Dr.
[**Last Name (STitle) 13310**] regarding your atrial fibrillation.
The following changes were made to your medications:
1. Hold Lisinopril - can restart if blood pressure increases
2. Take Acyclovir until [**2140-10-28**]
3. Take Meropenem until [**2140-10-29**]
4. Take Albuterol/Atrovent nebulizers as needed for shortness of
breath
5. Heparin drip until INR [**1-26**] for 2 consecutive days
6. Take Citalopram daily
If you experience worsening abdominal pain, fevers, chills,
shortness of breath, chest pain, or any other concerning
symptoms, please call your primary doctor or return to the
emergency department.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow up with your primary doctor within the next [**12-25**]
weeks.
An appointment with your cardiologist has been made for you:
Cardiology:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13310**]
Date/Time: [**2140-11-4**] 11a
Phone: [**Telephone/Fax (1) 25076**]
|
[
"427.31",
"482.1",
"998.59",
"428.0",
"786.09",
"272.4",
"054.9",
"V58.61",
"401.9",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10701, 10771
|
5136, 8977
|
331, 469
|
11022, 11095
|
3460, 5113
|
12570, 12866
|
2748, 2753
|
9118, 10678
|
10792, 11001
|
9003, 9095
|
11119, 12547
|
2768, 3441
|
277, 293
|
497, 2524
|
2546, 2595
|
2611, 2732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,485
| 126,801
|
41887
|
Discharge summary
|
report
|
Admission Date: [**2168-10-15**] Discharge Date: [**2168-10-20**]
Date of Birth: [**2145-11-1**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Trauma: s/p MVC
Major Surgical or Invasive Procedure:
[**2168-10-15**]
1. Trauma laparotomy.
2. Evacuation of massive hematoma.
3. Splenectomy.
4. Left tube thoracostomy insertion.
History of Present Illness:
22F s/p MVC rollover polytrauma including hemopneumothorax,
high grade splenic lac, left rib fractures, L2 transverse
process
fracture. Pt was the unrestrained driver in a high-speed MVC, in
which the vehicle rolled multiple times and she was ejected
approximately 100ft. She was reported to be GCS 15 at the scene.
She was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital where she was found to
have left-sided rib fractures with an associated pneumothorax,
for with a pigtail catheter was placed. She was med flighted in
stable condition to [**Hospital1 18**] for further management.
Past Medical History:
left labrum tear s/p hip surgery x3
Social History:
Patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] Ballet dancer and also goes to school and
works for real estate co.
denies ETOH, drug, tobacco use
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2168-10-15**]
HR: 131 BP: 134/102 Resp: 18
Constitutional: CONSTITUTIONAL:
intubated/sedated
EYES: No orbital rim tenderness or stepoffs; no racoon eyes
ENMT: Midface stable; No malocclusion; No septal hematoma
NECK: Supple; No cervical midline tenderness; No stepoffs;
BACK: No back midline tenderness; no stepoffs
CARD: s1, s2
RESP: Normal chest excursion with respiration; breath sounds
clear and equal bilaterally; pigtail in anterior chest in
2nd intercostal space on left
ABD: Soft, non-distended; non-tender;
EXT: dp2+; lac on right foot, ecchymosis on right knee
PELVIS: Pelvis stable
SKIN: Warm, dry, no rash; no c/c/e; DP2+
Pertinent Results:
[**2168-10-18**] 05:10AM BLOOD WBC-16.5* RBC-3.21* Hgb-9.2* Hct-27.7*
MCV-87 MCH-28.6 MCHC-33.1 RDW-13.3 Plt Ct-242
[**2168-10-17**] 08:35AM BLOOD Hct-29.6*
[**2168-10-17**] 02:00AM BLOOD WBC-18.4* RBC-3.57* Hgb-10.1* Hct-30.6*
MCV-86 MCH-28.2 MCHC-32.9 RDW-13.4 Plt Ct-203
[**2168-10-15**] 01:35PM BLOOD WBC-18.1* RBC-4.30 Hgb-12.4 Hct-36.5
MCV-85 MCH-28.8 MCHC-33.9 RDW-13.6 Plt Ct-167
[**2168-10-18**] 05:10AM BLOOD Plt Ct-242
[**2168-10-16**] 04:09AM BLOOD PT-14.7* PTT-41.4* INR(PT)-1.3*
[**2168-10-18**] 05:10AM BLOOD Glucose-69* UreaN-5* Creat-0.4 Na-136
K-4.0 Cl-106 HCO3-21* AnGap-13
[**2168-10-17**] 02:00AM BLOOD Glucose-77 UreaN-4* Creat-0.5 Na-134
K-3.8 Cl-103 HCO3-22 AnGap-13
[**2168-10-18**] 05:10AM BLOOD Calcium-7.9* Phos-2.1* Mg-2.0
[**2168-10-15**] 09:15PM BLOOD Lactate-1.1
[**2168-10-15**] 09:35AM BLOOD Glucose-104 Lactate-2.4* Na-141 K-4.0
Cl-111* calHCO3-17*
[**2168-10-15**] 12:11PM BLOOD freeCa-1.17
[**2168-10-15**]: chest x-ray:
IMPRESSION:
1. Lateral left seventh rib fracture.
2. Left upper lobe contusion and pulmonary edema.
3. Small left basilar pneumothorax and pneumomediastinum. This
is likely
related to #1, although esophageal injury cannot be excluded.
4. ETT 2 cm from carina, please retract 2-4 cm.
[**2168-10-15**]: CT scan of the chest:
IMPRESSION:
1. High-grade splenic rupture with disruption of the capsule and
large
hemoperitoneum. Hyperdense fluid layering in the left paracolic
gutter,
consistent with extravastion of contrast from prior CT. Intact
splenic hilum and intact splenic artery and vein.
2. Small left pneumothoraces, anterior and posteromedial, with
anterior chest tube terminating in the anterior pneumothorax.
3. Bilateral pulmonary opacities likely contusions, left greater
than right, and small left hemorrhagic pleural effusion with
adjacent atelectasis.
4. Endotracheal tube terminating just above the carina.
Retracting 3 cm is
recommended.
5. Multiple left rib fractures with left subcutaneous emphysema
layering
along the left chest and flank.
6. Stranding around the right common femoral and superficial
femoral arteries without evidence for active extravasation;
correlation with recent instrumentation attempt is recommended
[**2168-10-15**]: CT scan of the head:
1. CT evidence for acute intracranial process.
2. Mild expansion of the left temporalis muscle with overlying
soft tissue
stranding, consistent with known ecchymosis and suggestive of
intramuscular hematoma
[**2168-10-15**]: CT scan of the c-spine:
IMPRESSION:
1. No evidence for cervical spine fracture.
2. Biapical pulmonary contusions, incompletely imaged.
[**2168-10-15**]: right ankle x-ray:
There is normal alignment without fracture or dislocation.
[**2168-10-17**] FOOT AP,LAT & OBL RIGHT:
Comminuted intra-articular fracture of the lateral aspect of the
base of the distal phalanx of the right great toe
Brief Hospital Course:
Ms. [**Known lastname **] was admitted under acute care surgery service on
[**2168-10-15**] for further evaluation and management of her injuries.
ICU course:
The patient was taken to the operating room on the day of
admission for Ex-lap with splenectomy, as well as placement of a
left chest tube, with removal of the pigtail catheter that was
placed at the OSH. She remained intubated postoperatively for
concern of blossoming of her bilateral pulmonary contusions.
Following admission to the TSICU she required significant
amounts of propofol and dilaudid to maintain adequate pain
control/sedation. Persistent tachycardia, hypertension responded
well to IVF boluses. Later UOP decreased with only marginal
response to crystalloid. Albumin 5% given. On POD 1 she was
extubated, her OG tube replaced by an NGT. Clinically cleared
c-spine. Xray R foot showed fracture of distal phalynx great
toe. POD 2 her NGT was removed and she was started on a full
liquid diet. Additionally, her chest tube was removed and she
was transferred to the surgical floor.
Floor course:
She remained alert and oriented throughout her floor course. Her
pain was frequently assessed and her medication regimen was
adjusted until she expressed adequate pain control on oral pain
medication. Her vital signs were monitored routinely and she
remained hemodynamically stable and afebrile. Her electrolytes
were monitored and repleted as needed. Her CBC was also
monitored; her hematocrit remained stable and her WBC count
trended downward toward normal from 18.4 on [**10-17**] to 12.7 on
[**10-19**]. Her supplemental O2 was weaned, incentive spirometry and
pulmonary toileting were encouraged. Her O2 saturation remained
in the high 90's on room air at the time of discharge. She
reported slight shortness of breath at times with exertion, but
her ambulatory O2 saturation was checked and she remained in the
mid to high 90's while ambulating around the unit. A chest xray
on [**10-18**] showed no visible pneumothorax and a small-to-moderate
left-sided pleural effusion that had not substantially changed
since her prior xray on [**10-17**] at the time of the chest tube
removal. On [**10-19**] she continued to complain of slight vertigo, ?
BPPV. She was not orthostatic and her gait remained steady.
Physical therapy was consulted and evaluated the patient on the
day of discharge, and determined the BPPV to be resolving. She
was instructed to follow up as an outpatient with her PCP if the
vertigo continued.
On [**10-18**] she was advanced to a regular diet which she tolerated
without nausea/vomiting. Her abdomen remained soft and
nondistended, and she was administered a bowel regimen of stool
softeners. She had a BM on the day of discharge. A foley
catheter was placed on admission, and was removed on [**10-18**], after
which she voided without difficulty. Her abdominal incision site
remained nonerrythematous without any signs of infections, and
staples remained in place with plan for removal at follow up in
[**Hospital 2536**] clinic.
Orthopedics was consulted for her great toe fracture who
recommended hard-soled surgical shoe to be worn until follow up
as an outpatient in [**12-20**] weeks.
Prior to discharge on [**2168-10-19**], she was administered the
meningococcal, pneumococcal and Haemophilus B Conj. vaccine
(given s/p splenectomy for ruptured spleen).
Medications on Admission:
none
Discharge Medications:
1. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: s/p MVC
Left rib fractures, [**6-25**] lateral, 10, 11 posterior
Splenic rupture
Left pneumothorax
L2 transverse process fracture
Fracture of right great toe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you involved in a car
accident. You sustained rib fractures, lower back fractures, a
collapsed left lung, a ruptured spleen, and a broken toe on your
right foot. You had a chest tube placed to re-expand your lung.
You went to the operating room to have your spleen removed.
Your vital signs are stable and you are preparing for discharge
home with the following instructions:
Please call your doctor or nurse practitioner 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.
*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.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-26**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking narcotic
pain medications.
Continue to wear the hard surgical shoe on your right foot and
follow up in the orthopedics clinic as instructed below.
Incision Care:
*Please call your doctor if you have increased pain, swelling,
redness, or drainage from the incision site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at your follow-up appointment.
You are being given a prescription for narcotic pain medication.
Take the medication as instructed. Do not drink alcohol or drive
while taking narcotics. Narcotics can cause constipation so
continue to take an over the counter stool softener such as
colace to prevent this.
Followup Instructions:
Please follow-up in the [**Hospital **] clinic with [**Doctor Last Name **]
Desroisers, N.P. (who works with Dr. [**Last Name (STitle) **] on the [**Location (un) **]
of the [**Hospital Ward Name 23**] Building on the [**Location 90937**] of [**Hospital1 18**] at 2:40 pm.
Call [**Telephone/Fax (1) 1228**] if you need to change this appointment
date/time.
You have an appointment scheduled in the Acute Care Surgery
clinic on Thursday [**2168-10-27**] at 4:15 pm. The clinic is located on
the [**Location (un) 470**] of the [**Hospital Ward Name **] buidling on the [**Hospital Ward Name 517**] of [**Hospital1 18**],
[**Hospital Unit Name **]. Call [**Telephone/Fax (1) 600**] if you need to change this
appointment date/time. You staples will be removed at this
appointment.
You should also follow up with your primary care provider at
your convenience after discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2168-10-20**]
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25,949
| 116,199
|
15426
|
Discharge summary
|
report
|
Admission Date: [**2113-7-23**] Discharge Date: [**2113-8-23**]
Date of Birth: [**2040-6-19**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Thoracentesis.
Thallium myocardial viability study.
Intubation.
Central line placement.
Echocardiogram.
History of Present Illness:
Mr. [**Known lastname 44755**] is a 73 year old man transfered from an outside
hospital with chest pain and ecg changes.
Patient has past medical history of ESRD on HD for 5 years, PAF,
CVA, anemia, CAD s/p MI, Aortic stenosis. Patient was admitted
to [**Hospital3 4107**] last month with an MI. His hospital course
was complicated by bradycardic arrest, MRSA pneumonia, C diff
colitis. He was discharged to NESH 3.5 weeks ago. Since this
admission he has had worsening mental status with dementia.
On the day of admission he complained of chest pain [**9-20**]
radiating to his right shoulder. This was relieved only after 3
NTG. BP was stable; HR was 105-113 during this episode. He was
transfered to [**Hospital3 417**] Hospital where ECG showed
intermittant rate related RBBB and LVH with strain. Patient was
pain free on arrival and remained pain free. He was given one
aspirin. TnI was 0.2 and the patient was transfered here for
management of ACS.
On arrival here the patient had 10/10 chest pain. ECG showed
sinus tachycardia with LVH and strain. Pain resolved with one
sublingual nitroglycerin. TnT here 0.6, and CK is 51.
Currently the patient denies chest pain, shortness of breath,
abdominal pain, nausea, vomiting. He reports frequent diarrhea.
He has h/o orthopnea, PND but denies pedal edema. He has SOB
with ambulation.
Past Medical History:
1. ESRD on HD for 5 years
2. diverticulosis
3. GI bleed
4. PAF
5. CVA 2 years ago, with residual left sided weakness
6. CAD s/p MI (echo [**5-19**] with inferior hypokinesis)
7. Anemia
8. Cardiac arrest
9. GERD
10. OSA on CPAP 16 cm with 1 L oxygen
11. Moderate Aortic stenosis (echo in [**Month (only) 547**] at OSH)
Social History:
Lives at home with his wife. Stopped smoking in [**2105**].
Family History:
non contributory
Physical Exam:
T 98.0 HR 110 BP 138/59 RR 24 O2 sat 99% on 4L
Gen: elderly gentleman, appearing older than stated age, lying
in bed, in NAD.
HEENT: PERRL, EOMI, sclera anicteric, MM dry.
Neck: No JVD, no LAD.
Lungs: coarse BS bilaterally, anteriorly and posteriorly.
Expriatory wheezes.
CV: Regular with no MRG appreciated.
Abd: soft, distended, tender in the RUQ with guarding, no
rebound. active bowel sounds.
Ext: no clubbing, cyanosis or edema. Weak pulses bilaterally.
Neuro: sleepy but arousable. Follows commands. oriented to self,
place, but states date is [**2012**]. Strength 5/5 on the right and
4+/5 on the left lower extremity (can resist minor force) and
[**6-15**] on the right upper extremity and [**5-16**] on the left upper
extremity (cannot resist any force). Reflexes are 2+ in the left
patella and bicepts and 1+ on the right. Toes downgoing on right
and equivocal on left.
Pertinent Results:
OSH: 18.7\ /593 [**Age over 90 **]|95|25 /108 CK 30 MB 2.5 TnI 0.2 BNP >
5000
/40.3\ 5.3|30|5.9\
INR 2.5 DDimer 1409
LABS HERE:
[**Age over 90 **] |93|32 / 99 AGap=23
4.9 |26|6.4\
8:30p CK: 38 MB: Notdone Trop-*T*: 0.63
7:45p CK: 51 MB: Notdone Trop-*T*: 0.62
Ca: 10.0 Mg: 2.2 P: 3.7
ALT: 16 AP: 93 Tbili: 0.6 Alb:
AST: 22 LDH: 172 Dbili: TProt:
[**Doctor First Name **]: 54 Lip: 46
TSH:Pnd
MCV 92
17.7\12.1/569
/37.8\
N:87.5 Band:0 L:8.7 M:2.5 E:0.8 Bas:0.5
Hypochr: 1+ Anisocy: 1+ Polychr: 1+
Plt-Est: High
PT: 20.9 PTT: 28.5 INR: 2.9
ECG: 8:20 Sinus tachycardia at 107 bpm, LAD, RBBB, Q in III,
AVF. TWI in V1-V4, III, AVF. No STE or depression.
14:09 Sinus at 95 bpm. First degree AV block. LAD. Q in III,
AVF. Flat TW in I, AVL, V5-6. LVH with strain pattern.
14:20 Sinus at 96 bpm. First degree AV block. LAD. Q in III,
AVF. TW flat in I, avl, V5-6. LVH with strain pattern.
18:47 Sinus at 106 bpm. RBBB. LAD. TW normalization in I, AVL,
V5-6. Q in III, AVF. TWI in V1-V4. No STE or depression.
19:39 Sinus at 104 bpm. LAD. TW flat in I, AVL, V5-6. Q in III,
AVF. LVH with strain pattern.
labs around time of GI bleed.
[**2113-8-17**] 01:25PM BLOOD PT-14.2* PTT-36.6* INR(PT)-1.3
[**2113-8-17**] 08:07PM BLOOD PT-15.4* PTT-80.0* INR(PT)-1.6
[**2113-8-18**] 04:32AM BLOOD PT-14.5* PTT-63.0* INR(PT)-1.4
labs on discharge
[**2113-8-23**] 06:12AM BLOOD PT-21.0* PTT-33.7 INR(PT)-2.9
[**2113-8-23**] 06:12AM BLOOD WBC-10.0 RBC-3.44* Hgb-10.2* Hct-32.5*
MCV-94 MCH-29.7 MCHC-31.5 RDW-20.7* Plt Ct-335
[**2113-8-23**] 06:12AM BLOOD Glucose-79 UreaN-23* Creat-4.5*# Na-145
K-3.6 Cl-105 HCO3-28 AnGap-16
[**2113-8-23**] 06:12AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.7
Brief Hospital Course:
This 73 year old gentleman with a history of ESRD on HD,
ischemic cardiomyopathy, EF 35%, PAF, h/o CVA, h/o CAD s/p MI
who was initially transferred here from [**Hospital3 4107**] on
[**2113-7-23**] with chest pain, intermittent RBBB/LVH, TropI 0.6, CK
51. [**Hospital3 **] course notable for bradycardic arrest, MRSA
pna, C diff colitis and was d/c to rehab. with MRSA pneumonia, C
diff colitis.
.
On admission here, pt thought not to have acute ischemia;
finished course of PO vanco for c diff and IV vanco for MRSA
pna. His mental status was noted to be poor, thought to be [**3-15**]
delerium. Dialysis was continued. Wished for CTA to r/o PE, but
pt has iodine allergy. Had abnl cxr so v/q not pursued either.
Passed swallow study on [**7-25**] and [**7-31**].
.
[**7-25**], pt had resp distress but cxr showed layering pleural
effusions L>R, BNP [**Numeric Identifier 44756**].
.
[**7-26**], patient had another episode of tachypnea, hypoxia at HD
and was transferred to the [**Hospital Unit Name 153**] for further mngt. In [**Hospital Unit Name 153**], he
was rapidly weaned to nasal cannula, CPAP at night (has OSA).
SOB thought to be multifactorial from volume overload, pleural
effusions, AF w/ RVR. Leukocytosis to 13-14 persisted but ID
work up negative besides his previous known infections, as
above. Effusion not tapped since patient's resp status improved
(he also apparently refused per record).
.
[**7-29**] Recurrence of tachypnea, tachycardia, hypotension on [**7-29**]
that was thought [**3-15**] aspiration vs flash pulm edema vs mucous
plugging, again improved w/o intervention. Aggressive chest PT
was initiated. Cards consulted who wished to optimize his CHF
mngt w/ Ace-i, cont amio/bb and stop digoxin. EF now 25% with
new akinesis. Cardiac cath considered for concern of recurring
ischemia (INR elevated [**3-15**] coumadin, so held off for some time).
Vanco was started on [**8-1**] for GPC's in sputum and increased
secretions.
.
[**8-1**] With clinical improvement was transferred to general
medicine [**Hospital1 **]. Cath tentatively planned for [**8-7**], pt started on
heparin today for stroke ppx since INR now.
[**2113-8-5**] Had HD session w/o incident and had acute onset of resp
distress w/ sats 83% approx 30 min after arrival on floor. MICU
team near by and helped evaluate patient. VS at that time were T
96.3 BP 108/60's HR 90's RR 30's sats 83% NRB (was 98% 2L
previous to this). Pt confused but semi-alert, not mentating,
not comuunicative. ABG 7.42/40/49 on NRB. Code blue called for
impending resp arrest. pt w/ pulse; ekg NSR 90's old TWI's in
V1-V5. Intubated and brought to MICU.
.
MICU stay Underwent throacentesis with 1700 cc of serous fluid
removed which was transudative. He was thought to have flash
pulmonary edema. He was initially on a levophed gtt for
hypotension, but with fluid boluses he was weaned off the gtt.
[**8-7**]
-weaned off all pressors,
-seen by cardiology and they decided to defer catherization
until the patient was stable from a respiratory standpoint.
-Patient's stool was positive for C diff. He was started on
Flagyl for a ten day course. He was also
-started on levofloxacin/flagyl for empiric treatment of
aspiration pneumonia.
[**8-8**].
-extubated, transferred to general medicine wards
.
General medicine [**Hospital1 **] stay.
[**Date range (1) 44757**]
This period was characterized by recurrent episodes of chest
pain, respiratory distress, hypotension, and tachycardia. No
EKG changes accompanied these. Aggressive suctioning with O2
therapy successfully resolved all of these episodes, and it was
felt these episodes were secondary to mucus plugging. Chest PT,
nebulizer therapy, and mucolytic therapy were instituted with
success.
.
[**8-16**] Episode of 200 cc coffee ground emesis after HD. Emesis
guiaiac positive, stool guaiac negative. PTT was
supratherapeutic GI consulted, felt endoscopy would not be of
benefit unless catheterization performed.
.
[**8-17**] Thallium viability performed revealed no reversible defects,
as no tissue could be recovered by reperfusion, Cardiology
decided catheterization would not benefit the patient and signed
off. Per there recommendations, beta blocker and ACEi therapy
were titrated up. GI signed off.
[**8-18**] Thoracentesis performed 2L removed transudative negative for
gram stain and culture, largely for respiratory comfort.
Respiratory function notably improved after this, with somewhat
less oxygen requirement, and more vigorous cough reflex. Lungs
clear to auscultation. Pt had only one minor episode of
respiratory distress after this time.
[**8-21**] Wife met with attending, Dr. [**Last Name (STitle) **], and elected to change
pt status to DNR/DNI.
In summary this is a 73 year old Caucasian gentleman with a
prior history of coronary artery disease s/p myocardial
infarction, paroxysmal atrial fibrillation on amiodarone and
anticoagulation, ischemic cardiomyopathy EF 25%, end stage renal
disease on hemodialysis. He was admitted for non-ST elevation
MI, since admission his course has been complicated by recurrent
respiratory distress with chest pain and hypotension and
necessitating one intubation, pneumonia, upper GI bleed from
supratherapeutic INR, and C. dificile
on discharge this patients issues are as follows.
Resp distress: Improved s/p thoracentesis and with nebulizer,
chest PT and mucinex therapy. Mucus plugging was likely cause
of his recurrent resp distress. No recent sign of pneumonia.
Prior episode of pneumonia during stay successfully treated with
levofloxacin. No EKG changes have occured during these
episodes.
Ischemic heart disease: EF of 25%, now with new akinesis.
Unfortunately, invasive procedures will no longer benefit the pt
owing to the lack of viable tissue left. We have attempted to
optimize medical management using beta blocker and ace inhibitor
for protection of remainder of myocardium.
PAF: Appears stable, on amiodarone and now transitioned to
Coumadin for anticoagulative therapy last INR: 2.9.
End Stage Renal Disease: On hemodialysis Tuesday, Thursday,
and Saturday. On epogen for anemia. Appreciate work of renal
team in managing fluids.
Sepsis: Pt was septic requiring pressors x 3, resolved in MICU.
h/o MRSA pneumonia.
GI bleed: No further episodes of GI bleed since [**8-16**]; this was
probably secondary to his supratherapeutic INR
C. Dificile: On discharge, he will be on day 10 of 14
DVT prophylaxis: Coumadin
Anemia: Likely from chronic disease, ESRD, on epogen.
Hypothyroid: On replacement.
Code: DNR/DNI per wife as of [**2113-8-21**]
Medications on Admission:
Amiodarone 200 mg po daily
Lipitor 10 mg po daily
Aspirin 81 mg daily
Celexa 20 mg daily
Levoxyl 25 micrograms daily
Prevacid 30 mg daily
Provigil 100 mg daily
Nephrocaps 1 cap daily
Coumadin 2.5 mg daily
Lorazepam 0.5 mg q 8 hr prn
Vancomycin 250 mg po three times a day
colace 100 mg po daily
xopenex q 6 hr
atrovent q 6 hr
epogen 12,000 unit sq M,W, F
lactinex 2 tab po bid
megace 800 mg daily
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Solution
Injection ASDIR (AS DIRECTED).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
11. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for Oral Thrush.
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Course to complete 2 weeks of
therapy on [**2113-8-27**].
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours).
16. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Please do NOT give on hemodialysis days.
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
18. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Please do NOT give on hemodialysis days.
20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
21. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO at bedtime.
22. Compazine 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
Non-ST elevated MI
Sepsis with hypotension.
End stage renal disease now on hemodialysis.
Congestive heart failure (ischemic cardiomyopathy.
Coronary artery disease.
Clostridium difficile infection.
Recurrent respiratory distress with mucus plugging.
Gastrointestinal bleed.
Paroxysmal atrial fibrillation.
Anticoagulative therapy
Discharge Condition:
Stable.
Stable.Still requiring oxygen 2-3 L by NC or face mask.Chest
pain free.
Discharge Instructions:
Please return to hospital if respiratory distress, chest pain
recurs. Please return if coffee ground or bloody vomiting
recur.
Followup Instructions:
Rehabilitation facility.
Please see PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] in [**8-20**] days.
|
[
"995.92",
"244.9",
"414.8",
"428.0",
"427.31",
"038.9",
"933.1",
"285.9",
"585",
"507.0",
"518.81",
"511.9",
"410.71",
"466.0",
"785.52",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"93.90",
"39.95",
"96.6",
"96.56",
"96.71",
"34.91",
"33.23",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14058, 14136
|
4896, 11487
|
296, 402
|
14509, 14590
|
3139, 4873
|
14767, 14893
|
2205, 2223
|
11935, 14035
|
14157, 14488
|
11513, 11912
|
14614, 14744
|
2238, 3120
|
246, 258
|
430, 1771
|
1793, 2112
|
2128, 2189
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,108
| 115,115
|
43295
|
Discharge summary
|
report
|
Admission Date: [**2148-12-7**] Discharge Date: [**2149-1-2**]
Date of Birth: [**2085-7-5**] Sex: F
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Trileptal / Dilantin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
[**2148-12-10**]: Simultaneous liver and kidney [**Month/Day/Year **]
[**2148-12-11**]: Bronchoscopy
[**2148-12-24**]: Ultrasound-guided right thoracentesis
[**2148-12-25**]: Ultrasound-guided left thoracentesis.
History of Present Illness:
63 yo female with polycystic kidney/liver with ESLD and ESRD on
HD, h/o budd chiari, h/o ICH from ruptured [**Doctor Last Name **] aneurysm,
discharged on [**12-5**] after a prolonged hospitalization for anemia,
SBP, now presents from rehab after a witnessed episode of
aspiration this morning during breakfast leading to tachypnea
and
dyspnea. She was transported to ED and was intubated in ED
because she respiratory rate was 40-50. Meanwhile, she had 100
degree in her rectum temp.
ROS:: unobtainable because of sedation
Past Medical History:
- [**Month/Day (4) 18048**] (autosomal dominant w renal/liver involvement, c/b [**Doctor Last Name **]
aneurysmal bleed and ESRD)
- ESLD with recent MELD in high 20s
- multiple liver cysts
- ESRD [**12-31**] [**Month/Day (2) 18048**] now s/p bilateral nephrectomies
-Liver & Kidney [**Month/Day (2) 1326**] [**2148-12-10**]
- subarachnoid hemorrhage 2/2 L MCA [**Doctor Last Name **] aneurysm s/p surgical
clipping c/b peri-operative hemorrhagic stroke resulting in
right hemiparesis([**2136**])
- HTN
- secondary hyperparathyroidism
- anemia
- acidosis
- nephrolithiasis
- stress fracture of the right ankle.
- seizure disorder
Social History:
Had been at rehab prior to admission. At baseline, she lives
with her husband in [**Name (NI) 86**]. Ambulates with a cane (more recently
from rehab with walker). Worked as a city planner. She was
transferred directly from rehab today.
Smoking: denies
EtOH: 1 glass of wine/day
Drugs: denies
Family History:
Father and son with [**Name (NI) 18048**].
F - died in his 80s, [**Name (NI) 18048**] and prostate cancer
M - died at [**Age over 90 **] yrs of old age
Sister w [**Name (NI) 11398**].
Physical Exam:
Pt is sedated and intubated and on pressers
T99 P105-119 R 16-17 BP 62-69/39 SaO2 96%40%
HEENT: PREEAL, oral dry
NECK: supple, no JVD, no LN
Chest: clear, no wheezing
CVS: regular, no murmur
Abd: distent, I was unable to appreciate if pt has tender or not
because pt is sedated. BS present. liver enlarged significantly.
The skin in her low abd was significant red.
Ext: pitting edema
Lab:
129 93 51 86 AGap=19
5.6 23 2.9
CK: 65
96
16.1 8.8 321
29.8
N:84.9 L:6.2 M:6.8 E:1.6 Bas:0.5
PT: 37.9 PTT: 39.3 INR: 3.9
Pertinent Results:
[**2149-1-2**] 07:15AM BLOOD WBC-10.6 RBC-3.40* Hgb-10.3* Hct-31.7*
MCV-93 MCH-30.4 MCHC-32.5 RDW-17.3* Plt Ct-428
[**2148-12-30**] 05:49AM BLOOD PT-10.8 PTT-26.2 INR(PT)-0.9
[**2148-12-31**] 07:57AM BLOOD Glucose-119* UreaN-91* Creat-2.0* Na-135
K-4.9 Cl-101 HCO3-23 AnGap-16
[**2149-1-1**] 05:40AM BLOOD Glucose-95 UreaN-95* Creat-1.9* Na-135
K-5.1 Cl-102 HCO3-23 AnGap-15
[**2149-1-2**] 07:15AM BLOOD Glucose-95 UreaN-95* Creat-1.8* Na-140
K-5.6* Cl-107 HCO3-22 AnGap-17
[**2149-1-1**] 05:40AM BLOOD ALT-11 AST-16 AlkPhos-111* TotBili-0.9
[**2149-1-2**] 07:15AM BLOOD ALT-9 AST-17 AlkPhos-110* TotBili-0.9
[**2149-1-2**] 07:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9
[**2148-12-30**] 05:49AM BLOOD calTIBC-166* Ferritn-GREATER TH TRF-128*
[**2148-12-19**] 02:15AM BLOOD TSH-27*
[**2148-12-19**] 02:15AM BLOOD T4-3.0* T3-61*
Brief Hospital Course:
Hypotension and respiratory distress were most likely 2nd to
aspiration vs sepsis vs pulmonary edema. Pt was intubated and
on started on antibiotics. She was treated with improvement in
the MICU.
On [**2148-12-10**], a liver and kidney donor became available. She was
cleared for surgery. On [**12-10**], a liver was transplanted by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Attempt was made to do a splenectomy prior to the
renal [**Last Name (NamePattern1) **], but this was too difficult secondary to the
extremely large polycystic liver wrapped around the spleen. She
was very coagulopathic. Bleeding was controlled then a renal
[**Last Name (NamePattern1) **] was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with a 6-French
double-J stent inserted into the ureter and a JP drain. Drains
were also placed posterior to the liver and at the hilum as well
as in the splenic bed.
Induction immunosuppression was administered consiting of ATG,
cellcept and steroids. Postop, she was transferred to the SICU
for management. Postop course was complicated requirining CVVH
for delayed renal graft function. LFTs trended down immediately.
Duplex of the liver was appropriate. Renal duplex US
demonstrated lack of diastolic flow of the interpolar arteries,
with an RI of 1. There was flow within the main renal vein. She
experienced ATN.
She failed to extubate and a trache was considered, but
eventually with improving renal/liver function, she managed to
extubate on *****. Of note, on [**12-19**], TSH was noted to be 27, T3
61 and T4 3.0. Levothyroxine was increased. She remained
tachypneic and short of breath. On [**12-11**], a bronchoscopy was
performed as she has aspirated bilious appearing emesis. BAL was
performed in the anterior segment of the left upper lobe.
Twenty ml of greenish aspirate was obtained. Culture grew
10-100,000 colonies of Enterobacter Cloacae. She was treated
with Cipro for 14 days from [**Date range (1) **]. Vancomycin was
administered from [**12-10**] thru [**12-17**]. Micafungin was administered
from [**12-11**] trough [**12-25**] for antifungal coverage per [**Month/Year (2) **]
protocol. On [**12-15**], a CVL was removed to simplify lines. Tip was
sent for culture and grew VRE. Linezolid was started on [**12-18**]
until stop date [**12-30**].
CXR demonstrated bilateral pleural effusions with right greater
than left. On [**12-24**], a right thoracentesis was done removing 1.5
liters. This fluid was cultured and had no growth. A left
thoracentesis was done on [**12-25**] for 1100ml. This also had no
growth on culture. Respiratory status improved with room air
sats of 99%. Respiratory rate averaged 20 bpm. BP ranged between
130/90-145/100. She was mantained on lopressor.
CVVHD was continued during most of her SICU stay. As urine
output increased, CVVHD was stopped on [**12-26**]. Creatinine averaged
0.6 on dialysis. Once off CVVHD, creatinine increased to 2.0 on
[**12-30**]. By [**1-2**], creatinine had decreased to 1.8 with daily urine
output averaging 2.9 liters/day on Lasix. A daily dose of oral
Lasix was prescribed. Florinef was added on [**12-30**] for
hyperkalemia. On [**12-30**], she was transfused with 2 units of PRBC
for a hct of 23.3.
Immunosuppression consisted of ATG (75mg each dose x3 doses),
cellcept and steroid taper. Prograf was initiated on postop day
2 and adjusted daily per trough levels with goal achieved. Goal
prograf was 10.
On [**12-28**], she transferred out of the SICU to the Med [**Doctor First Name **] Unit.
Preop, she was very debilitated with muscle wasting. Postop, she
was more so and required PT. A [**Doctor Last Name **] lift was recommended for
transfers. Rehab was recommended. Diet was poorly tolerated and
nasojejeunal tube feedings were administered using Novasource
Renal. She did have some diarrhea. Stools were negative for
C.diff. Cellcept dosing was adjusted to qid with decreased GI
side effects.
On [**12-26**], a speech and swallow evaluation was completed without
s/sx of aspiration at bedside. She appeared safe for initiation
of regular diet, thin liquids, pills whole with thin.
Energy level improved overall although she is still very
debilitated. She will transfer to [**Hospital3 **] in [**Hospital1 8**]
with twice weekly lab monitoring. Tunnelled HD line should be
flushed with saline/heparin every 2-3 days as she is currently
off dialysis. Immunosuppression should be managed only by the
[**Hospital1 1326**] Service at [**Hospital1 18**]. A TSH should be repeated in [**3-4**]
weeks as Levoxyl was increased on [**12-19**].
Medications on Admission:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for diaper rash.
10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for diaper rash .
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours): Must give standing, and even
wake out of bed for this overnight.
12. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO DAILY
(Daily): Please titrate to [**1-31**] bowel movements daily.
15. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4
PM: Monitor INR at least once weekly while taking this
medication.
17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q 8H (Every 8 Hours): Must give standing, and even
wake out of bed for this overnight.
19. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours): Patient has been
receiving this standing in the days prior to discharge, as has
been frequently SOB. Must give standing, and even wake out of
bed for this overnight.
20. Heparin (Porcine) 1,000 unit/mL Solution Sig: One (1) flush
Injection PRN (as needed) as needed for line flush: Withdraw 4
ml prior to flushing with 10 mL NS followed by heparin as above.
21. Medication
Critic-Aid - apply in morning to buttocks and prn throughout the
day as needed to maintain seal
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
2. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
3. Florinef 0.1 mg Tablet Sig: One (1) Tablet PO
Monday-Weds-[**Month/Day (1) 2974**].
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
7. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection ASDIR (AS DIRECTED): see printed scale.
8. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
wheezing/SOB.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
follow taper.
15. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
17. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp <110 or HR <60.
19. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
20. Dextrose 50% in Water (D50W) Syringe Sig: 12.5 gm
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Hospital1 8**]
Discharge Diagnosis:
[**Hospital1 18048**] s/p liver/kidney txp
Delayed renal graft function [**12-31**] ATN
Hypothyroidism
Pleural effusions
Discharge Condition:
Stable/Fair
A+Ox3
Ambulatory status: requires intensive rehab
Discharge Instructions:
Please call the [**Month/Day (2) **] clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
take or keep down food, fluids or medications, jaundice,
decreased urine output, weight gain of 3 pounds in a day, pain
over liver/kidney [**Telephone/Fax (1) **].
Call if there are problems with the post pyloric feeding tube or
intolerance to the tube feeds such as diarrhea
Labwork every Monday and Thursday with results faxed to
[**Telephone/Fax (1) **] clinic at [**Telephone/Fax (1) 697**]. Monitor the incision for
redness, drainage or bleeding
Monitor urine output daily and keep record to send with patient
to clinic.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) 156**] [**First Name3 (LF) **] SOCIAL WORK Date/Time:[**2149-1-9**] 2:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2149-1-9**] 3:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2149-1-16**] 3:40
Completed by:[**2149-1-2**]
|
[
"511.9",
"285.21",
"571.5",
"E947.8",
"507.0",
"572.8",
"244.9",
"403.91",
"997.5",
"996.81",
"599.70",
"751.62",
"438.20",
"E879.8",
"286.7",
"584.5",
"458.29",
"753.13",
"482.83",
"518.81",
"585.6",
"276.1",
"E878.0",
"999.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"00.93",
"55.69",
"97.49",
"96.72",
"33.24",
"34.91",
"55.23",
"38.95",
"96.04",
"96.6",
"00.14",
"50.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12643, 12706
|
3677, 8304
|
326, 541
|
12871, 12935
|
2830, 3654
|
13659, 14085
|
2076, 2262
|
10691, 12620
|
12727, 12850
|
8330, 10668
|
12959, 13636
|
2277, 2811
|
266, 288
|
569, 1097
|
1119, 1749
|
1765, 2060
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,827
| 183,182
|
24075
|
Discharge summary
|
report
|
Admission Date: [**2116-12-25**] Discharge Date: [**2116-12-27**]
Date of Birth: [**2053-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Arterial clot
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 61228**] is a 63 yo man with a history of advanced
colorectal cancer on erbitux (C6D1 [**2116-12-4**]) who is a direct
admit from the [**Hospital **] clinic for a right brachial arterial
clot. The patient began having RUE pain 2 weeks ago while on a
trip to [**Location (un) 5354**]. He called his oncologist on his return on
[**2116-12-21**] and was scheduled for urgent evaluation. An ultrasound
found no RUE DVT. At his clinic visit afterward, he reported no
swelling although he noted that his right arm felt somewhat cold
and a "dead weight". He also c/o numbness in the arm distal to
the elbow. He was able to move his arm and hand although it felt
better in a sling. He was started on aspirin due to concern for
an arterial clot and scheduled for RUE doppler today. The
doppler today showed a right brachial artery clot at the
antecubital fossa. Exam following this revealed a strong left
radial putse but a notably weaker to absent right radial pulse
as well as SBP decreased by 20-30 mmHg in the RUE. His fingers
did not appear blue or mottled. He denied any fevers or chills.
Vascular was called and recommended admission to the OMED
service. An echocardiogram was done to evaluate an embolic
source; this read is pending.
.
Of note, the patient's erbitux treatment has been suboptimal due
to his side effect of severe fatigue. His dose frequency was
reduced from weekly to every other week, and this has been
further complicated by his travels during the holidays. In this
setting, his CEA level has been rising from 2.5 on [**2116-12-4**] to 7
today (8.0 on [**2116-12-25**]). Pt reportedly has also been more
depressed so was started on an antidepressant by his primary
oncology team today.
.
Currently, the patient denies any pallor, poikilothermia, pain,
or paresthesias in the R distal arm. He denies chest pain,
shortness of breath, nausea, vomiting, diaphoresis,
palpitations, dysuria, diarrhea, constipation. Denies orthopnea,
PND. Endorses exertional L calf pain with 300 yds, resolves with
3 min of rest. He states that the quality/nature of this pain
has not changed in years.
Past Medical History:
Mr. [**Known lastname 61228**] is a patient with advanced colorectal cancer who
has multiple therapies in the past. He also has experienced
significant toxicities from both 5-FU and oxaliplatin based
therapies. His tumor was tested for DPD deficiency and he indeed
was found to have a high susceptibility for toxicity from 5-FU
based therapies based on heterozygous mutation in his DPYD gene.
This was tested through Myriad Laboratories. His tumor also is
wild type for K-RAS, and therefore, cetuximab based therapy has
been initiated. Erbitux has caused acneiform rash, and he has
felt profound fatigue with this regimen. He also had an episode
of mild renal insufficiency of unclear etiology but this has
resolved. Occasional doses of erbitux have been held.
ERBITUX DOSING:
[**4-15**] - [**2116-4-29**] C1W1-3 Erbitux
[**5-12**] - [**2116-6-4**] C2W1-4Erbitux
[**2116-6-26**] - C3W1
[**2116-7-3**] - treatment held - rash, acute renal
failure,hypotension.
[**2116-7-10**] C3 D15 erbitux
[**2116-7-17**] C3 D22 erbitux
[**2116-7-24**] C4 D1 Erbitux
[**2116-8-14**] C4 D22 Erbitux
[**2116-9-18**] C5 D1
[**2116-11-6**] C6 D1 (Every other week, 2 doses/cycle; decreased for
fatigue/rash)
[**2116-11-25**] C7 D1
s/p palliative radiation therapy (to 30Gy) for metastatic
colorectal cancer with symptomatic left-sided abdominopelvic
lymphadenopathy, [**3-/2116**]
s/p left hepatic lobectomy, cholecystectomy, and Segment VI mass
resection, [**6-/2113**]
.
Other Past Medical History:
Hypertension
S/p appendectomy and tonsillectomy when he was a child
s/p Right internal jugular vein thrombus, [**6-/2112**]
Social History:
He owns a metal machining company. He is married. He has a
15-pack-a-year smoking history
- etOH: occasional
- Illicits: none
Family History:
Negative for colon cancer, uterine cancer, or
any other GI malignancies.
Mother - HTN
Two Sisters - HTN
Aunt - gastric cancer
Physical Exam:
GEN: NAD, AAOx3
VS: 97.6 75 114/82 20 94% RA
HEENT: NCAT
CV: RRR s mrg
PULM: CTAB s rwr
ABD: obese, S, +BS, NT/ND
LIMBS & NEURO:
RUE: mildly cool distal to elbow, no sensory deficits, [**4-21**] motor
str, 1+ radial pulse
LUE: WWP, 2+ radial pulse
RLE: 3+/5 hip flexion strength, faintly palpable DP/PT, pt
reports sensory deficits, impaired proprioception
LLE: 5/5 strength, palpable DP/PT
Pertinent Results:
ADMISSION LABS:
[**2116-12-25**] 12:21PM BLOOD WBC-13.6* RBC-4.75 Hgb-13.8* Hct-42.4
MCV-89 MCH-29.0 MCHC-32.4 RDW-13.5 Plt Ct-251
[**2116-12-25**] 12:21PM BLOOD Neuts-84.7* Lymphs-10.3* Monos-3.0
Eos-1.9 Baso-0.2
[**2116-12-25**] 01:00PM BLOOD PT-11.4 PTT-23.3 INR(PT)-0.9
[**2116-12-25**] 12:21PM BLOOD Gran Ct-[**Numeric Identifier **]*
[**2116-12-25**] 12:21PM BLOOD UreaN-23* Creat-1.7* Na-135 K-5.3* Cl-105
HCO3-23 AnGap-12
[**2116-12-25**] 12:21PM BLOOD ALT-13 AST-13 AlkPhos-67 TotBili-0.5
[**2116-12-25**] 06:05PM BLOOD CK(CPK)-60
[**2116-12-26**] 12:00AM BLOOD CK(CPK)-56
[**2116-12-26**] 05:42AM BLOOD CK(CPK)-44*
[**2116-12-25**] 06:05PM BLOOD CK-MB-5 cTropnT-1.73*
[**2116-12-26**] 12:00AM BLOOD CK-MB-NotDone cTropnT-1.60*
[**2116-12-26**] 05:42AM BLOOD CK-MB-NotDone cTropnT-1.74*
[**2116-12-25**] 12:21PM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.2* Mg-1.6
[**2116-12-25**] 12:21PM BLOOD %HbA1c-11.0*
[**2116-12-25**] 06:05PM BLOOD Triglyc-244* HDL-40 CHOL/HD-4.3
LDLcalc-81
[**2116-12-25**] 12:21PM BLOOD CEA-7.0*
---------------
DISCHARGE LABS:
[**2116-12-27**] 04:11AM BLOOD WBC-9.2 RBC-4.30* Hgb-12.6* Hct-38.0*
MCV-88 MCH-29.3 MCHC-33.2 RDW-13.9 Plt Ct-228
[**2116-12-27**] 04:11AM BLOOD PT-11.8 PTT-53.5* INR(PT)-1.0
[**2116-12-27**] 04:11AM BLOOD Glucose-237* UreaN-21* Creat-1.5* Na-139
K-4.8 Cl-106 HCO3-25 AnGap-13
[**2116-12-27**] 04:11AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.5*
---------------
STUDIES:
EKG: NSR at 80 with normal axis and intervals. >[**Street Address(2) 4793**]
eleavations in II, III, and aVF and depressions in V2-V4 and
somewhat less remarkable in aVL. Deep S waves in V1. Compared
to [**2115-12-24**], the Q waves are more makred and the ST segments have
become more concave with new reciprocal changes.
.
OTHER STUDIES:
[**2116-12-22**] RUE ultrasound: No acute right upper extremity DVT.
.
[**2116-12-25**] RUE arterial duplex (prelim): Right brachial artery clot
near antecubital fossa.
.
[**2116-12-25**] TTE: The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the basal inferolateral wall. The remaining
segments contract normally (LVEF = 55 %). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Very suboptimal image quality. Normal left
ventricular cavity size with mild regional systolic dysfunction
c/w CAD. No definite valvular pathology identified. No definite
structural cardiac source of embolism identified.
.
[**2116-10-9**] CT torso w/ contrast:
1. Soft tissue mass within the retroperitoneum causing
left-sided hydronephrosis and proximal left hydroureter is not
significantly changed.
2. No significant change in tiny bilateral pulmonary nodules.
3. Peritoneal nodules, less confluent in appearance.
4. Status post left hepatic lobectomy. Right hepatic lobe liver
hypodense lesion is slightly decreased in size when compared to
prior exam.
.
CT Head W/O Contrast [**2116-12-25**]:
No intracranial hemorrhage or mass-effect. If concern persists
for intracranial mass, further evaluation with MR is recommended
Brief Hospital Course:
This is a 63 year old man with hypertension and metastatic colon
cancer presenting with new arterial thrombus and found to have
ECG changes consistent with myocardial ischemia but with flat
CK's.
.
1) Right brachial arterial thrombus: Patient was found to have a
right brachial artery clot seen on ultrasound doppler on [**2116-12-25**],
so was admitted for management. He is predisposed to
thromboembolism likely due to history of active malignancy.
Patient was started on heparin gtt after a head CT ruled out
large mets, and he was evaluated by vascular surgery for
thrombectomy. Given that patient was asymptomatic with heparin
gtt, vascular surgery decided that no surgical intervention was
necessary, and patient can be managed by anticoagulation. The
ideal management would be life-long lovenox; however, patient
was adamant about not taking lovenox since he does not want to
have bruises on his abdomen. After extensive discussions,
patient did agree to take lovenox until INR is therapeutic on
coumadin. Patient was loaded with coumadin 7.5mg on the day of
discharge, and was given prescription of coumadin at 5mg daily.
His oncologist Dr. [**First Name (STitle) **] will call patient tomorrow to schedule
INR checks and follow up appointment. Patient was also told to
follow up with vascular surgery in [**1-21**] weeks.
.
2) EKG changes: After patient was admitted to OMED, his ECG
revealed concerning ECG changes including ST depressions
laterally and elevations in II, III, and aVL. Enzymes revealed
an elevated troponin (but in the context of chronic kidney
disease) with flat CK's suggesting a subacute event. Patient
denied any recent shortness of breath, chest pain, orthopnea,
PND, syncope, or presyncope. Because of the EKG changes,
patient was transferred to CCU for further management. His EKG
changes were impressive for inferior ischemia, but given old Q's
and flat CK's, lack of symptoms, essentially normal EF, it did
not seem that this was new acute ischemia. Patient was
continued to aspirin, beta-blocker, started on statin, and he
was already on heparin for arterial thrombus. Patient was
discharged home with aspirin, toprol XL and high dose
atorvastatin.
.
3) Metastatic Colon Cancer: Patient will need further staging
and management given difficulties in maximizing therapy. The
original plan was to transfer patient back to OMED from CCU for
restaging. However, patient insisted on leaving despite
multiple conversations with him about the importance of staying.
After discussing with heme-onc, patient was discharged home
with plan to have re-staging later, possibly as an outpatient.
.
4) Depression/Irritability: Patient was likely undergoing major
depressive episode vs adjustment disorder exacerbated by
steroids. Patient will require outpatient psychiatry evaluation
and treatment, and need close followup.
.
5) CKD: Baseline creatinine around 1.4-1.6, due to previous
obstructive uropathy. His creatinine was stable during this
hospital stay.
.
6) FEN: Patient was given regular/Cardiac diet, and he tolerated
POs well.
.
7) PPx: Patient was on heparin drip for DVT prophylaxis.
.
8) Code: FULL
Medications on Admission:
Clindamycin 1% gel apply [**Hospital1 **]
Clindamycin 1% soln apply [**Hospital1 **]
Dexamethasone 8mg daily (erbitux rash)
Gabapentin 300mg [**Hospital1 **]
Hydroxyzine 10mg tid prn itchiness
Lisiopril 10mg daily
Methylpheidate 5mg [**Hospital1 **] prn fatigue
Metoprolol succinate 100mg daily
Oxycodone 5mg q4h prn pain
Sertraline 50mg daily
Sodium polystyrene sulfonate 15g qhs prn elevated potassium
Zolpidem 5mg qhs
ASA 325mg daily
Docusate sodium
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Enoxaparin 100 mg/mL Syringe Sig: One (1) ml Subcutaneous [**Hospital1 **]
(2 times a day).
Disp:*30 ml* Refills:*0*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*14 Tablet(s)* Refills:*0*
10. Hydroxyzine HCl 50 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for itching.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Metastatic colorectal cancer
- Right brachial artery thrombus
Secondary diagnoses:
- Hypertension
- history of right internal jugular vein thrombus in context of
port-a-cath
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 61228**].
You were admitted to [**Hospital1 18**] for a blood clot in your right arm.
You were given a blood thinner to treat the clot, and your were
also seen by vascular surgery. Since your symptoms are
controlled by blood thinners, the vascular surgery service
determined that you do not need surgery to remove the clot. You
will be discharged with an oral blood thinner called "coumadin"
with subcutaneous lovenox bridging. Once your INR is within
therapeutic range, you can discontinue lovenox. As we discussed
extensively, it is very important for you take the blood
thinners to avoid complications from the blood clot such as limb
ischemia and even limb loss.
While you were in the hospital, you were found to have EKG
changes, and you were transferred to cardiac intensive care unit
for management. Since your were not having an acute cardiac
event, no intervention was not required.
Your oncologist, Dr. [**First Name (STitle) **], [**First Name3 (LF) **] call you tomorrow to arrange INR
checks and the next follow up appointment with him.
Your medications have been changed.
Added:
- coumadin
- lovenox
- lipitor
Followup Instructions:
Dr. [**First Name (STitle) **] will call you tomorrow to arrange for follow up
appointment.
Please also call vascular surgery at ([**Telephone/Fax (1) 8343**] to have a
follow up appointment in the next 2-4 weeks.
|
[
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"197.6",
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"411.89",
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"403.90",
"197.7",
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"311",
"154.8",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12908, 12914
|
8282, 11434
|
331, 338
|
13154, 13154
|
4834, 4834
|
14524, 14742
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4279, 4407
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11938, 12885
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|
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|
13040, 13133
|
278, 293
|
366, 2489
|
4850, 5876
|
13168, 13275
|
3993, 4119
|
4135, 4263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,283
| 167,935
|
23733
|
Discharge summary
|
report
|
Admission Date: [**2127-3-29**] Discharge Date: [**2127-4-10**]
Date of Birth: [**2060-4-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
acute mi, respiratory failure
Major Surgical or Invasive Procedure:
percutaneous coronary intervention
History of Present Illness:
67M with PMH of DM2, HTN, and obesity who presented to OSH
w/SSCP x 1 hour on [**2127-3-28**]. +N, V, and diaphoresis. EKG
demonstrated STE V2-V3 so started on heparin and aggrestat and
transferred to [**Hospital1 18**] for cath. Angiography here revealed 100%
new occlusion of LAD, moderate LMCA stenosis, and mildly diffuse
disease of RCA. PCI stenting of LAD with 3.5 x 16 DES. Pt had
been feeling well PTA, including playing golf 2d PTA.
Past Medical History:
1. Type II diabetes mellitus
2. Colon CA
3. Gout
Social History:
Lives at home with wife.
Family History:
NC
Physical Exam:
VS: HR 97 BP 89/63 on IABP
Gen: intubated, sedated.
HEENT: PERRL, MMM, no icterus
CV: normal S1/S2, no murmurs, rubs, gallps.
Pul: CTA b/l
Abd: obese, nt, nd +bs
Ext: distal pulses intact
Pertinent Results:
[**2127-3-29**] 04:51AM BLOOD WBC-25.9* RBC-4.44* Hgb-14.0 Hct-41.2
MCV-93 MCH-31.5 MCHC-33.9 RDW-13.2 Plt Ct-360
[**2127-3-29**] 04:51AM BLOOD PT-14.8* PTT-63.8* INR(PT)-1.4
[**2127-3-29**] 04:51AM BLOOD Glucose-411* UreaN-24* Creat-1.3* Na-135
K-4.2 Cl-100 HCO3-16* AnGap-23
[**2127-3-30**] 04:29AM BLOOD ALT-130* AST-434* LD(LDH)-[**2076**]*
CK(CPK)-1532* AlkPhos-65 Amylase-146* TotBili-0.5 DirBili-0.1
IndBili-0.4
[**2127-3-29**] 04:51AM BLOOD CK(CPK)-3381*
[**2127-3-30**] 04:29AM BLOOD CK-MB-395* MB Indx-25.8* cTropnT->25
Echo [**3-30**]: mild symmetric LVH. LV cavity size is normal. Overall
LV sys fxn severely depressed, EF 15%. Ant and septal severe HK
and lateral and apical akinesis are present with some some
preservation of inferior wall motion.
Brief Hospital Course:
1) Cardiovascular:
a) Pump: Mr. [**Known lastname **] was admitted after a large anterior wall MI.
An echocardiogram performed on [**2127-3-30**] showed anterolateral
wall akinesis with an approximate EF of 15%. He was initially
supported on levophed, dopamine and dobutamine, i addition to an
intraaortic balloon pump. Dopamine was weaned off on [**3-30**],
levophed was weaned off on [**4-2**]. Dobutamine was off [**4-3**] but
restarted [**4-4**]. Beta blockers and ace-inhibitors were held
while he was maintained on pressors and ionotropic support.
For diuresis, he was placed on a lasix drip at 5-15mg/hr.
Because he was on so many drips, despite double-concentrating
them, he required lasix plus nesiritide for adequate diuresis.
Pt passed away on [**2127-4-10**]
b) Rhythm: during cardiac catheterization, he had a brief
episode of ventricular tachycardia. An amiodarone drip was
started and then discontinued on [**3-30**]. On [**3-31**] however, he went
into rapid atrial fibrillation which was attributed to volume
overload. Cardioversion was attempted twice, followed by
re-loading amiodarone, and another attempt. After diuresis and
several hours on amiodarone, he reverted to normal sinus rhythm
spontaneously. He was loaded with 400 PO TID x1 week followed
by 400mg [**Hospital1 **] [**Last Name (un) 2557**] [**4-7**].
c) Ischemia: his initial ischemic event was likely an acute
occlusive thrombus of LAD. He is status post placement of drug
eluting stents to his LAD.
Aspirin and atorvastatin were continued. Heparin drip was
continued for his IABP and also for his atrial fibrillation and
low ejection fraction.
Coumadin will be started prior to discharge.
# ID/Respiratory: Post-cath, the patient was found to have
leukocytosis and fevers.
He was initially treated with six days of levofloxacin
([**Date range (1) 12721**]) for empiric treatment of a positive UTI and this was
changed to vanco + flagyl for empiric treatment MRSA pneumonia.
He was briefly on aztreonam, flagyl and cipro for broad coverage
given some gram negative rods seen on a sputum culture. On
[**4-5**] the patient developed an erythematous maculopapular rash on
his flanks and chest. On the suspicion that this was a
drug-rash, and given that the predominant organism on his
cultures were gram positive cocci, only the vanco-flagyl were
continued.
# Renal: ARF likley due to poor forward flow, dye load. Urine
sed w/hyaline casts. ?ATN. Baseline Cr is 1.3. Creatinine
improved with dobutamine despite agressive diuresis with I>>>O.
We continued to monitor creat closely while diuresing.
# Anemia: having little drops every few days - ?phlebotomy
- transfuse 1 unit pRBC's [**4-5**]
.
# Nutrition ?????? NGT insertion for medications. Maintain NPO.
Nutrition consult.
.
# Endo: We maintained tight glucose control with an insulin
dripg.
# PPx- lansoprazole
# Access-RIJ, left A-line, L arterial sheath with balloon pump
now d/ced, PIV. Successfully placed L-IJ x2 on [**4-6**] but 1 port
didn't flow both times so concerned about clot. Plan to switch
central lines given continued ID concerns.
# Code: FULL CODE
Medications on Admission:
Aspirin
Lopressor
Aggrastat
Heparin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Deceased
|
[
"785.51",
"507.0",
"995.92",
"414.01",
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"427.31",
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"428.0",
"584.5",
"482.41",
"V10.00",
"250.00",
"274.9",
"278.00",
"410.11",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.04",
"00.17",
"96.72",
"96.6",
"36.07",
"36.01",
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icd9pcs
|
[
[
[]
]
] |
5196, 5205
|
1953, 5081
|
301, 337
|
5272, 5283
|
1165, 1930
|
938, 942
|
5167, 5173
|
5226, 5251
|
5107, 5144
|
957, 1146
|
232, 263
|
365, 808
|
830, 880
|
896, 922
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,602
| 155,624
|
47691
|
Discharge summary
|
report
|
Admission Date: [**2156-12-29**] Discharge Date: [**2157-1-5**]
Date of Birth: [**2084-1-10**] Sex: M
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old
male with left upper lobe mass that is increasing in size on
a repeat CT, palliative CAT scan to rule out lung cancer.
PAST MEDICAL HISTORY:
1. Emphysema.
2. Hypertension.
3. Coronary artery disease.
PAST SURGICAL HISTORY:
1. Inguinal hernia repair.
2. Knee surgery.
3. Left thyroid lobectomy.
4. Prostatectomy.
MEDICATIONS:
1. Moexipril 15 mg po q day.
2. Lasix 20 mg po q day.
3. Asthmacort two puffs b.i.d.
4. Atrovent two puffs t.i.d.
5. Lipitor 20 mg po q day.
6. Synthroid 0.1 mg po q day.
ALLERGIES: Seafood, shellfish and iodine.
SOCIAL HISTORY: The patient has a 35 year history of
smoking, but has since quit. The patient is a social
drinker.
PHYSICAL EXAMINATION: The patient weighs 218 pounds.
Temperature on admission was 96.2. Heart rate 61. Satting
97% on room air. The patient's blood pressure was 140/80.
The patient was alert and oriented times three. The patient
had a regular rate and rhythm. Examination of the lungs were
clear to auscultation. Abdomen positive bowel sounds,
nontender, nondistended. Extremities, warm with no edema.
The patient had a stress pulmonary function tests on [**12-15**], which showed mild decrease in exercise capacity. FEV1
was 2.1 83% of predicted and FVC was 3 87% of predicted.
HOSPITAL COURSE: The patient was admitted to the Thoracic
Surgery Service and underwent a left upper lobectomy. The
patient had an open upper lobe wedge resection, left upper
lobe lobectomy and mediastinal lymph node dissection as well
as bronchoscopy and thoracoscopy. Postoperatively, the
patient was doing well. The patient was on neo for pressure
support. Chest tube was in place. The patient was weaned off
of neo. The patient was out of bed to chair and encouraged
to use incentive spirometry and chest physical therapy and
continue the epidural.
On postoperative day number one the patient was seen by the
pain service to follow the patient's pain. The patient was
also seen by the oncology service who had been following on
the issue of the left upper lobe mass. On postoperative day
number three the patient remained afebrile with stable vital
signs. The patient's chest tube output had been adequate and
the patient was continued to be monitored. On postoperative
day number four the patient was afebrile with stable vital
signs. The patient had a distended abdomen and did not pass.
The patient was ordered Dulcolax suppositories. The patient
had a KUB, which showed a dilated loops of small bowel and
dilated colon. The general surgery was consulted who felt
that the increase in abdominal girth was consistent with
ileus due to the patient's pain medication. Per their
recommendations the patient was kept NPO with intravenous
fluids. The patient was weaned off of the narcotics and the
patient had a rectal tube to decompress the abdomen. The
repeat KUB revealed that the patient's abdominal distention
had decreased. The patient complained of no abdominal
tenderness, but had very soft distended abdomen. On
postoperative day number five the patient continued to do
well and remained afebrile with stable vital signs. The
patient ___________ removed and Foley removed and repeat
abdominal x-ray was obtained, which showed improvement in
symptoms. Rectal tube was removed that night on
postoperative day number six. The patient continued to do
well. Abdomen was slightly less distended compared to
previously and the KUB showed that the patient had resolution
of the small bowel dilatation and overall improvement of the
abdominal distention.
On postoperative day number six the patient continued to do
well. On postoperative day number seven the patient was
advanced to clear liquid diet. On postoperative day number
seven the patient was advanced to a regular diet, which the
patient tolerated without any difficulty and the patient was
discharged to home.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Status post left upper lobectomy.
2. Status post knee surgery.
3. Status post left thyroid lobectomy.
4. Status post inguinal hernia repair.
5. Emphysema.
6. Hypertension.
7. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po q day.
2. Moexipril 50 mg po q day.
3. Lipitor 20 mg po q day.
4. _________ propionate 110 micrograms two puffs b.i.d.
5. Ipratropium bromide two puffs b.i.d.
6. Levoxyl 100 micrograms po q day.
7. Acetaminophen 500 mg q 6 hours prn pain.
8. Colace 100 mg po b.i.d.
9. Motrin 600 mg po q.i.d. prn pain.
10. Maalox prn.
FOLLOW UP PLANS: Please follow up with Dr. [**Last Name (STitle) 175**]. Please
call his office for a follow up appointment. Please follow
up with primary care physician. [**Name10 (NameIs) 357**] call for a follow up
appointment.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2157-1-5**] 09:46
T: [**2157-1-5**] 09:48
JOB#: [**Job Number 100729**]
|
[
"458.29",
"560.1",
"E878.8",
"492.8",
"414.01",
"401.9",
"162.3",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.29",
"40.3",
"33.23",
"96.09",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
4155, 4366
|
4389, 5254
|
1490, 4073
|
435, 764
|
905, 1472
|
178, 327
|
349, 412
|
781, 882
|
4098, 4134
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,076
| 147,889
|
55681
|
Discharge summary
|
addendum
|
Name: [**Known lastname **],[**Known firstname **] Unit No: [**Unit Number 3730**]
Admission Date: [**2150-1-23**] Discharge Date: [**2150-2-2**]
Date of Birth: Sex: F
Service:
ADDENDUM: This is a Discharge Summary Addendum for [**Known firstname **]
[**Known lastname **] who had been planned to be discharged to a
rehabilitation facility. However, secondary to persistent
fever, hypotension, and hemoptysis this discharge was
delayed.
Over the next several days the patient's fevers continued to
spike, and the patient was placed on ceftazidime to cover to
gram-negative rods as well as vancomycin and Flagyl. The
patient's laboratories became consistent with disseminated
intravascular coagulation, and she became persistently
hypotensive requiring pressor support as well as intravenous
fluids.
Over the next several days, the patient appeared to improve
from a hemodynamic standpoint and was weaned off pressors.
At this time, it was decided that the patient should be
continued on her mode of cardiopulmonary resuscitation not
indicated and no aggressive measures taken for resuscitation.
It was decided that were she to require pressors that it
would not be indicated due to medical futility to restart
these. Ms. [**Known lastname **] continued to show no evidence of any
higher cortical function throughout this period.
Over the next two days, the patient's blood pressure began to
drop and she subsequently became hypotensive. The patient's
family was communicated with daily, and the patient was not
aggressively resuscitated.
On the morning of [**1-28**], the patient was found to be
without a heart rate or heart rhythm. She remained
unresponsive as was her baseline. Her pupils were fixed and
nonreactive. The time of death was 9:14 in the morning. Her
son was [**Name (NI) 178**] and declined a postmortem examination. She
was discharged to the morgue on the morning of [**1-28**].
DR.[**Last Name (STitle) 3731**],[**First Name3 (LF) **] 12-AEW
Dictated By:[**Name8 (MD) 3732**]
MEDQUIST36
D: [**2150-2-2**] 20:55
T: [**2150-2-3**] 07:39
JOB#: [**Job Number 3733**]
|
[
"287.5",
"286.6",
"345.3",
"707.0",
"038.40",
"427.31",
"786.3",
"785.51",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,618
| 116,556
|
5318+5319+5320+55661
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2157-5-6**] Discharge Date: [**2157-5-8**]
Service: ACOVE-MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
gentleman presenting from the [**Hospital3 **] facility
for altered mental status described as "lethargy" times
approximately four days, as well as question of worsening
anemia. The patient is [**Country 532**] speaking and upon arrival in
was minimally responsive to even noxious stimuli. The eye
position was midposition. The pupils were felt to be
minimally reactive. The patient was not following commands,
even commands in Russian.
The patient in the Emergency Department became increasingly
awake and alert, status post dosing of Narcan although it
Emergency Department was negative for narcotics. On repeat
examination at the time the patient arrived at the floor,
through an interpreter, the patient was awake and alert and
not sure why he was at the [**Hospital1 188**] or really the name of the facility.
Even he denied fever, chills, chest pain, shortness of
breath, headache, abdominal pain, change in vision, change in
strength, change in sensation. He stated he had been
somewhat short of breath approximately seven days ago but had
not experienced the symptoms since that time.
The patient is reported to have had an episode of decrease in
blood pressure on [**2157-5-2**], at the [**Hospital3 **]
Center. He does have a recent history of discharge from the
[**Hospital1 69**] on [**2157-4-30**], for anemia
and transient renal insufficiency.
Additionally, please note that the patient had a recent
admission to the [**Hospital1 69**] between
[**2157-4-13**], and [**2157-4-16**], for atrial fibrillation with hospital
course complicated by an exaggerated response to Lopressor
producing unresponsiveness and hypotension, noting that the
patient's vital signs in the Emergency Department at this
admission were stable at a heart rate of 75, blood pressure
122/90, respiratory rate 20, and pulse oximetry 97% on four
liters.
PAST MEDICAL HISTORY:
1. Recent discharge [**2157-4-29**], for anemia.
2. Parkinson's disease.
3. Depression with psychotic features with a history of a
suicide attempt.
4. Colon cancer, status post hemicolectomy in [**2153**].
5. Benign prostatic hypertrophy.
6. Gastroesophageal reflux disease.
7. History of atrial fibrillation.
8. History of C. difficile.
9. History of loculated pericardial effusion with
pericarditis.
10. Alert and oriented times two at baseline.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg p.o. b.i.d.
2. Neurontin 500 mg p.o. t.i.d.
3. Atenolol 25 mg p.o. q.d.
4. Aspirin 81 mg p.o. q.d.
5. Sinemet 25/100 two tablets p.o. q.i.d. and one tablet
p.o. q.h.s.
6. Ibuprofen 600 mg p.o. t.i.d.
7. Prevacid 30 mg p.o. q.d.
8. Flomax 0.4 mg p.o. q.d.
9. Seroquil 100 mg p.o. b.i.d. (noting that had been
recently decreased from 150 mg p.o. b.i.d.
PHYSICAL EXAMINATION: In the Emergency Department, afebrile
at 98.4, pulse 74, blood pressure 144/63, respiratory rate
12, 97% in room air and 100% on four liters. General -
somnolent, opening eyes to verbal commands, not following
commands, normocephalic and atraumatic. The pupils are
equal, round, and reactive to light and accommodation. The
neck was supple. Chest was clear. Cardiac - regular rate
and rhythm. The abdomen was benign. Rectal examination was
negative for occult blood. There was 1+ edema bilaterally.
The skin was warm and dry. The patient as noted was
somnolent and unable to follow commands.
The examination when the patient arrived on the floor the
night of [**2157-5-6**], the patient was afebrile, blood pressure
148/100, pulse 53, respiratory rate 18, pulse oximetry 93% in
room air. In general, the patient is awake, alert in no
apparent distress. There was a question of jugular venous
distention but the pulsus was 4 to 5 (not elevated). The
oropharynx was exceptionally dry. There was noted to be poor
dentition. There were upper dentures in place with white
exudate versus dry mucus in the posterior aspect of the
oropharynx. The patient was oriented to [**Location (un) 4551**] and the year
[**2156**], with the month being [**2156**], on repeated questioning. He
could pick the type of building as hospital from a list but
could not generate this on his own. The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. The strength was full and symmetrical
to limited examination in the upper and lower extremity
flexors and extensors. Cardiac examination was unremarkable
with regular rate and rhythm, no murmurs were noted. There
were dry crackles at the bases, right greater than the left,
and otherwise the patient was clear to auscultation
bilaterally. The abdomen demonstrated a well healed midline
scar, soft, nontender abdomen with normal abdominal sounds.
There is no edema noted. The patient was awake and alert in
no apparent distress.
LABORATORY DATA: White blood cell count at the time of
admission was 5.3, hematocrit 28.8, with normal differential.
Platelet count was 317,000. Coagulation studies were
essentially unremarkable. Urine was negative for urinary
tract infection. Chem7 sent at the time of admission on
[**2157-5-6**], at 1:30 p.m. was sodium 139, potassium 3.8,
chloride 98, bicarbonate 28, blood urea nitrogen 20,
creatinine 1.5**a significant value. Glucose 111. Calcium
8.8, magnesium 1.6, phosphate 2.9. Arterial blood gases in
the Emergency Department on [**2157-5-6**], at 3:40 p.m. had a pH
7.47, pCO2 46, pO2 77. Urine culture is pending at the time
of this dictation.
Head CT was performed on [**2157-5-6**], with the following
impression: "No acute intracranial pathology, brain
atrophy". Chest x-ray was performed on [**2157-5-6**], with the
following impression: "Persistent pericardial and pleural
effusions".
HOSPITAL COURSE: The patient was admitted with the above
complaints with having received doses of Narcan in the
Emergency Department. Although the toxicology screen was
negative for narcotics, the patient's mental status improved
markedly although there was no clear cause and effect
relationship for this change.
By the time the patient arrived at the medical floor, his
mental status was apparently more or less at the baseline.
His creatinine was noted to be elevated to 1.5 and the
patient was gently hydrated with 750 ccs of normal saline
overnight with a resultant decrease in the patient's
creatinine to 0.9 the day following admission, noting that
the patient's mouth had been quite dry at the time of
admission and it was moist on the morning following
admission.
The etiology of the patient's mental status change observed
in the Emergency Department with stable vital signs and
unclear precipitant of resolution at this time is still
unclear, but possibilities are felt to include dehydration
which has now been corrected, the possibility of narcotic
ingestion responding to Narcan, the patient's psychiatric or
neurologic problems including depression or [**Name (NI) 5895**]
disease although Parkinson's disease the Sinemet has not
recently changed. The Seroquil has recently been decreased
and is currently being held though these possibilities appear
less likely than others.
Head CT was performed as noted above to rule out acute
intracranial pathology including bleeding. Additionally,
please note that the geriatric fellow raised the possibility
of seizure although the patient is not reported to have had
positive phenomenon including tonoclonic movements or eye
movements consistent with seizure during the period of
unresponsiveness. The possibility of occult seizure is still
open to question and the patient will be observed for
approximately 24 additional hours to insure that such an
episode does not recur.
At this time, the patient's mental status is approximately
baseline and the patient is stable and will be observed for
the forthcoming day with reassessment at that time and
possible discharge back to [**Hospital3 **] Center in
the morning.
MEDICATIONS ON DISCHARGE: (at the time of this dictation)
1. Lopressor 25 mg p.o. b.i.d. (to be changed to Atenolol 25
mg p.o. q.d. prior to the time of the patient's discharge to
[**Hospital3 **]).
2. Flomax 0.4 mg p.o. q.d.
3. Prevacid 30 mg p.o. q.d.
4. Sinemet 25/100 two tablets p.o. q.i.d. and one tablet
p.o. q.p.m.
5. Aspirin 81 mg p.o. q.d.
6. Colace 100 mg p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Dehydration.
2. Altered mental status possibly secondary to dehydration
or other factors yet to be determined.
Please note that additional diagnoses may be found in past
medical history.
CONDITION AT TIME OF DICTATION: Stable.
DISCHARGE PLAN: The current plan is for discharge back to
[**Hospital3 **] Center. The patient should not have
increased beta blocker without close supervision including
frequent blood pressure monitoring and neurologic checks as
he has a history of unresponsiveness and hypotension because
of sensitivity to beta blockade although he is stable on his
current dosing. Sedating medications should be avoided.
The patient should be closely monitored for signs of
dehydration and creatinine should be checked q.d. to q.o.d.
for one week versus signs for volume overload including pulse
oxygenation measured b.i.d. and on examination as the patient
may either need additional hydration or diuretic to insure
that he does not begin to become dehydrated, nor does he have
worsening of his pulmonary status.
DR.[**Last Name (STitle) **], [**First Name3 (LF) 177**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2157-5-7**] 11:51
T: [**2157-5-7**] 14:03
JOB#: [**Job Number 21687**]
Admission Date: [**2157-5-6**] Discharge Date: [**2157-6-1**]
Service: MEDICAL ICU
CHIEF COMPLAINT: Change in mental status.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 21688**] is an 86 year-old
Russian man initially admitted to the Medical Service on [**5-6**]
with a change in mental status.
The patient had been increasingly fatigued over the week
prior to admission becoming completely dependent on
activities of daily living. He had one episode of transient
hypertension. He was initially brought to the Emergency
Department for these complaints. At this point he was
minimally responsive and unable to follow commands. He
appeared dehydrated. Head CT at this point as well as
urinalysis and chest x-ray were negative. He initially
improved slightly after intravenous fluids. He was admitted,
however, over the subsequent weekend his mental status began
to decrease. A neurology consult was obtained.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2157-6-1**] 08:02
T: [**2157-6-1**] 08:23
JOB#: [**Job Number 21689**]
Admission Date: [**2157-5-6**] Discharge Date: [**2157-6-1**]
Service: MEDICAL ICU
CHIEF COMPLAINT: Change in mental status.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 21688**] is an 86 year-old
non English speaking Russian male with a recent history of
pericarditis presenting in the end of [**Month (only) 547**] with new onset of
atrial fibrillation and chest pain. He had ruled out for
myocardial infarction had a transthoracic echocardiogram
without evidence of tamponade and had been discharged to the
[**Hospital3 21690**] on a course of
non-steroidal anti-inflammatory drugs. While at [**Hospital1 5595**] he was
rate controlled and reportedly did well. On the [**5-18**] he was readmitted to [**Hospital1 188**] in mid [**Month (only) 116**] for a low hematocrit and was observed
overnight, found to be stable and returned to his nursing
home.
Over the week prior to this admission the patient was found
to be increasing fatigued and became completely independent
in his activities of daily living. Seraquel had been tapered
for 150 mg b.i.d. to 100 mg b.i.d. Additionally he had at
least one episode of hypotension where his blood pressure was
as low as 60/40 and was received a fluid bolus. His Atenolol
had been held and restarted the subsequent day at a decreased
dose.
On the day of admission the patient was again noted to be
anemic with a hematocrit of 25%. He was sent to the
Emergency Department where he was found to be lethargic
responding only to loud noises and noxious stimuli. He was
unable to answer questions even when asked in his native
tongue.
Given these findings a head CT was obtained, which was
negative for acute stroke or bleed and he was admitted to the
Medicine Service for further observation.
PAST MEDICAL HISTORY: 1. Pericarditis, idiopathic.
Initially treated empirically with non-steroidal
anti-inflammatory drugs. 2. PPD negative with no history of
tuberculosis. 3. Parkinson's disease. 4. Benign prostatic
hypertrophy. 5. Depression with psychosis, history of
suicide attempt. 6. Gastroesophageal reflux disease. 7.
Colon cancer status post hemicolectomy in [**2152**]. 8. History
of C-diff colitis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg po q day. 2.
Atenolol 50 mg po q day. 2. Sinemet 25/100 two tabs po
q.o.d., one tab q.p.m. 3. Ibuprofen 600 mg po t.i.d. 4.
Prevacid 30 mg q.d. 5. Flomax 0.4 q.d. 6. Seraquel 150 mg
b.i.d. 7. Multivitamins.
PHYSICAL EXAMINATION ON ADMISSION: The patient is an elderly
male lying in bed sleeping and responding to loud noise or
light in eyes, but only with grimace, did not answer
questions or follow commands. Vital signs temperature 98.4.
Heart rate 74. Blood pressure 144/63. Respiratory rate 12.
O2 sat 97% on room air. His pupils are equal, round and
reactive to light. His sclera were anicteric. He had dry
mucous membranes, very poor dentition. Dentures in place on
the upper. He had no JVP. His neck was supple. He was
noted at this point to have a regular rate with distant
heart sounds. Lungs were clear to auscultation anteriorly
and laterally with diminished breath sounds at the bilateral
bases. Abdomen was soft, obese, distended, nontender. His
extremities were warm with no edema.
LABORATORY DATA ON ADMISSION: White blood cell count 5.3,
68% polys, 23% lymphocytes, hematocrit 29, platelets 317, INR
1.2, PTT 27, sodium 139, potassium 3.8, chloride 98, bicarb
28, BUN 20, creatinine 1.5, glucose 111. Electrocardiogram
normal sinus rhythm at 70 beats per minute and borderline
axis, low voltage scooping of ST segments in V3 through V5.
HOSPITAL COURSE: Mr. [**Known lastname 21688**] was admitted to the Medical
Service in a nonresponsive state with a differential at that
point including toxic metabolic disorder, nonconvulsive
seizures, acute infection or overdose.
The subsequent several days after admission he became
increasingly less responsive and a neurology consult was
obtained. Additionally a lumbar puncture was performed.
Cerebral spinal fluid findings were significant for 1 white
blood cell, 245 red blood cells, normal protein and glucose.
An electroencephalogram was obtained to rule out
nonconvulsive status epilepticus, which showed nearly
continualized generalized epileptiform discharges without
clear correlation to observe right sided movements. There
was a suggestion of some left sided focality (or increased
amplitude of discharges). He was initially loaded on
Dilantin as well as phenobarbital. An MRI with gadolinium
was obtained to look for focal lesions or signs of hemorrhage
or stroke. At the initial Dilantin load, repeat
electroencephalogram was checked, which was largely
unchanged. At that point he was loaded on phenobarbital.
The MRI was obtained and was negative with no evidence of
acute infarct or mass lesion or bleed. HSV was sent on his
cerebral spinal fluid, which was negative as well.
Subsequent to the phenobarbital load the patient required
intubation for control and protection of his airway after
being found increasingly unresponsive. He was transferred to
the Medical Intensive Care Unit for further monitoring.
After this transfer a repeat electroencephalogram was
obtained and at this point was found no longer to be in
status epilepticus. He was continued on Dilantin maintenance
dose and phenobarbital maintenance dose. An aggressive
workup to elicit the source of his seizures was undertaken,
however, throughout the course of his long stay, this
returned negative. As mentioned an HSV/PCR was sent and was
negative. He was noted to have an elevated erythrocyte
sedimentation rate to 130 prompting a workup for temporal
arteritis including a biopsy of the left temporal artery,
which was negative. [**First Name8 (NamePattern2) 6**] [**Doctor First Name **] was negative as well. He was
empirically treated with a course of Acyclovir for a possible
case of hepatic encephalitis. However, there was no
improvement on this treatment.
After admission he was briefly hypernatremic for a period of
several days. This was corrected and he then became
hyponatremic again for a period of approximately two weeks
with sodiums to the low 130s, 132, 133. This was not felt to
be part of his neurological disorder. He was eventually
corrected by fluid restriction in his tube feeds.
Shortly after admission the patient did spike a fever to
approximately 102. It was felt this likely was secondary to
an aspiration pneumonia. He was treated with Ceftriaxone one
gram q 24 for a full course. He did grow staph coag negative
staphylococcus out of two sets of blood cultures and this was
thought to represent a source in the lungs. He defervesced
after a full course of antibiotics and had no further issues
from an infectious disease standpoint. It was considered that
his elevated sed rate and his neurological complications
might be secondary to an infectious source. An Infectious
Disease consult was obtained. The results of his cerebral
spinal fluid were reviewed and it was felt that it was
unlikely that any of his neurological issues might be
resulting from an undiscovered infectious source.
Given his history of pericarditis, pericardial effusions and
new onset atrial fibrillation from a prior admission,
cardiology was consulted. There was no role for a
pericardial tap at this point. He was rate controlled
initially with Lopressor and later started on a short
Amiodarone load at the suggestion of his cardiologist. He
remained in atrial fibrillation throughout his stay and did
not spontaneously convert. He was not started on
anticoagulation given the relative risks of anticoagulation.
While in the Intensive Care Unit he was initially intubated
as previously mentioned. After approximately ten days in the
Intensive Care Unit he was extubated after spending the
entire time of pressure support of 5 and 5, he did well after
extubation without evidence of overt secretions or
aspiration. He received tube feeds via nasogastric tube for
the majority and on approximately day twelve he had a G tube
placed for further feeding. He additionally at this point
had a PICC line placed for ongoing blood draws and any
further medication that might be required.
At the time of this dictation Mr. [**Known lastname 21688**] remains
unresponsive, although he will open his eyes partially to
deep sternal rub or loud voices. He continues to have
occasional seizure activity on electroencephalogram. His
goal Dilantin level has been 10 and he continues on
Phenobarbital. This continued nonresponsiveness may represent
a prolonged post ictal state in an elderly male with a
prolonged period of status epilepticus. It is felt by the
Neurology Service that it may take Mr. [**Known lastname 21688**] an
extensive period to recover from this. The plan at this
point is to have him transferred back to his nursing home
where he can continue to receive ongoing support with the
hope that he may slowly recover neurological function. The
results of his ongoing neurological workup is detailed above
have been negative completely to date. There are no further
studies planned at this time. He will be followed by
neurology while at [**Hospital 100**] Rehab.
Communications with Mr. [**Known lastname 21691**] family had been
primarily through his daughter, his son who lives in [**Name (NI) 4551**]
and two nieces. Decision making has been primarily through
consensus as Mr. [**Known lastname 21691**] daughter expressed a wish to
not be the primary decision maker in this case due to stress
despite the fact that she is the legal proxy by form. All
decisions were reviewed with his son in [**Name (NI) 4551**] prior to any
interventions and explicit informed consent was obtained from
him as well as from his nieces and his daughter. The
decision making was reviewed with the Ethic Service and found
to be acceptable. At the time of discharge his code status
remains a full code as his family has expressed their wishes
to do anything and everything possible for Mr. [**Known lastname 21688**].
DISCHARGE DIAGNOSES:
1. Nonconvulsive status epilepticus.
2. New onset seizure disorder.
3. Aspiration pneumonia.
4. Atrial fibrillation.
5. Parkinson's disease.
6. Depression with psychosis.
7. Hyponatremia.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: 1. Tube feeds, Respalor at 45 cc per
hour. 2. Heparin 5000 units subQ b.i.d. 3. Sinemet 25/100
two tablets per G tube q.i.d., one tablet per G tube q.p.m.
4. Prevacid 30 mg per G tube q.d. 5. Colace 100 mg per G
tube b.i.d. 6. Aspirin 81 mg po q day. 7. Nystatin powder
topical q.i.d. to groin. 8. Phenobarbital 60 mg per G tube
b.i.d. 9. Dilantin 200 mg po q.a.m., 100 mg po q noon,
q.h.s. whit tube feeds held one hour prior to dosage. 10.
Senna one tab per G tube q.d. 11. Amiodarone 200 mg po
b.i.d., to be decreased to 200 mg po q day on discharge. 12.
Keppra 500 mg b.i.d. per G tube. 13. Lopressor 25 mg per G
tube b.i.d. 14. Dulcolax 10 mg per G tube b.i.d. prn. 15.
Lactulose 10 to 15 cc per G tube q 8 hours prn.
DISCHARGE DISPOSITION: The patient will be discharged to
[**Hospital3 **] when an acceptable
bed is found.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2157-6-1**] 08:36
T: [**2157-6-1**] 08:50
JOB#: [**Job Number 21692**]
Name: [**Known lastname 3604**], [**Known firstname 3605**] Unit No: [**Numeric Identifier 3606**]
Admission Date: [**2157-5-6**] Discharge Date: [**2157-6-5**]
Date of Birth: [**2070-8-18**] Sex: M
Service: A-Cove
ADDENDUM: This is a Discharge Summary addendum to the
Discharge Summary dictated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
The patient was transferred to the medical floor on [**6-1**].
Due to the seizure activity seen on [**5-31**], the patient was
started on Keppra as an additional anticonvulsant. This was
titrated up over two days.
An electroencephalogram was done on [**6-3**] which showed no
seizure activity. The patient continued to have very minimal
responsiveness; usually not even responsive to noxious
stimuli such as sternal rub.
In the early morning of [**6-5**], the patient developed
respiratory distress. A code blue was initiated, but efforts
were unsuccessful. The patient passed away at approximately
3 a.m. on [**2157-6-5**].
CONDITION AT DISCHARGE: Deceased.
[**Name6 (MD) **] [**Last Name (NamePattern4) 3607**], M.D. [**MD Number(2) 3608**]
Dictated By:[**Last Name (NamePattern1) 3609**]
MEDQUIST36
D: [**2157-6-5**] 15:19
T: [**2157-6-9**] 10:10
JOB#: [**Job Number 3610**]
|
[
"780.01",
"427.31",
"296.24",
"507.0",
"530.81",
"345.3",
"276.1",
"276.5",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"34.91",
"38.21",
"43.11",
"96.04",
"96.6",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
22100, 23507
|
21073, 21269
|
21327, 22076
|
8102, 8462
|
13202, 13461
|
14622, 21052
|
2950, 5892
|
23522, 23790
|
11056, 11082
|
11111, 12709
|
14275, 14604
|
8736, 9831
|
12732, 13175
|
21294, 21303
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,471
| 129,558
|
7561
|
Discharge summary
|
report
|
Admission Date: [**2123-1-1**] Discharge Date: [**2123-1-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
blood in stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. [**Known lastname **] is a [**Age over 90 **] y/o M with PMH notable for glaucoma,
gout, and intermittent lower GI bleeding who presents from [**Company 191**]
to the ED today with several weeks of blood in his stools. The
patient states that he has had bright and dark blood in his
stools for several weeks. This problem happens every few months
per his report. He has had intermittent dizziness in the past
few days. He denies any chest pain or difficulty breathing. His
wife convinced him to come in for evaluation today. At [**Company 191**], the
patient's BP was 88/39 lying down and 79/40 standing. An
ambulance was called and he was brought to the [**Hospital1 18**] ED.
.
On arrival to the ED, the patient's initial vitals were T 97.5,
HR 84, BP 93/55, RR 18. His Hct was found to be 21.1 (last in
our system 28.5). Blood pressures ranged from 80s-110s systolic
in the ED. He receieved a total of 3 L NS and 1 U PRBCs. The 2nd
unit of blood was hanging on his arrival to the ICU. He also
underwent CT scan of the abdomen/pelvis due to intermittent
abdominal pain and cramping over the past few weeks; he did not
have any evidence of mesenteric ischemia. On rectal exam, the
patient was actually guaiac negative without any stool in the
vault. No obvious hemorrhoidal bleeding.
.
On arrival to the ICU, the patient denies any dizziness, chest
pain, difficulty breathing, or abdominal pain. He last noticed
bright and dark blood in his stools several days ago. He says
that he has had abdominal cramping "off and on" and has been
intermittently dizzy for several days. He denies any
nausea/vomiting or hematemesis.
Past Medical History:
PMH:
* h/o gout
* h/o hemorrhoids (seen in [**Hospital 7819**] Clinic for hemorrhoid
banding, also has been seen by Dr. [**Last Name (STitle) 1120**] with recurrent lower
GI bleeding
* glaucoma
* ETOH abuse
* BPH s/o TURP
* anemia, mild leukopenia
Social History:
Lives with wife in a 3-family home. Daughter and her children
live on the [**Location (un) 470**]. Patient had history of [**1-22**] drinks of [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5261**] per day as documented in [**Last Name (NamePattern1) **]. Prior tobacco, quit in
60s. Originally from [**Country **] but moved to US in [**2064**].
Family History:
noncontributory
Physical Exam:
PE: T: 97.9 BP: 104/54 HR: 100 RR: 10 O2 93% 2L NC
Gen: Pleasant, well appearing elderly gentleman in no acute
distress
HEENT: sclerae slightly pale, tongue moist & midline, pupils
small but reactive bilaterally
NECK: no lymphadenopathy or thyromegaly
CV: RRR, no murmurs
LUNGS: clear to auscultation bilaterally, no wheezing
ABD: soft, normoactive bowel sounds, nontender to palpation
EXT: warm, trace pitting edema in bilateral feet, DP pulses 2+
bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&O X 3, face symmetric, speaking clearly and in full
sentences, moving all extremities without difficulty
Pertinent Results:
***LABS ON ADMISSION***
[**2123-1-1**] 02:10PM PT-14.3* PTT-26.6 INR(PT)-1.2*
[**2123-1-1**] 02:10PM PLT COUNT-300
[**2123-1-1**] 02:10PM NEUTS-65.8 LYMPHS-23.2 MONOS-9.4 EOS-1.3
BASOS-0.4
[**2123-1-1**] 02:10PM WBC-2.8* RBC-2.31* HGB-6.2*# HCT-21.1*#
MCV-91 MCH-26.7* MCHC-29.2* RDW-17.4*
[**2123-1-1**] 02:10PM ALBUMIN-3.9
[**2123-1-1**] 02:10PM CK-MB-3
[**2123-1-1**] 02:10PM cTropnT-0.01
[**2123-1-1**] 02:10PM LIPASE-24
[**2123-1-1**] 02:10PM ALT(SGPT)-8 AST(SGOT)-12 CK(CPK)-44 ALK
PHOS-42 TOT BILI-0.3
[**2123-1-1**] 02:10PM GLUCOSE-87 UREA N-9 CREAT-1.2 SODIUM-142
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-28 ANION GAP-11
[**2123-1-1**] 02:13PM LACTATE-2.3*
[**2123-1-1**] 04:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2123-1-2**] 01:44AM BLOOD WBC-3.5* RBC-2.83* Hgb-7.8*# Hct-25.0*
MCV-88 MCH-27.6 MCHC-31.2 RDW-16.9* Plt Ct-231
[**2123-1-2**] 10:23AM BLOOD Hct-28.6*
.
CTA abd/pelvic
1. Colonic diverticulosis without evidence of diverticulitis.
2. Cardiac enlargement.
3. Aorta shows mild-to-moderate atherosclerotic calcification.
The
mesenteric vessels are patent. There is no evidence of bowel
ischemia.
4. Cholelithiasis.
5. Enlarged prostate.
.
CXR
FINDINGS: There is no evidence of pneumoperitoneum. The lungs
are clear with
no signs of congestive heart failure or pneumonia. The heart
demonstrates a
left ventricular shape configuration and is top normal in size.
There is mild
tortuosity of the aorta. The mediastinal contours are stable in
appearance.
The visualized osseous structures are unremarkable.
IMPRESSION: No evidence of pneumoperitoneum or pneumonia.
.
***LABS ON DISCHARGE***
[**2123-1-4**] 12:44PM BLOOD Hct-29.2*
[**2123-1-4**] 06:25AM BLOOD WBC-4.5 RBC-3.20* Hgb-8.9* Hct-28.5*
MCV-89 MCH-27.7 MCHC-31.1 RDW-16.1* Plt Ct-207
[**2123-1-4**] 06:25AM BLOOD Plt Ct-207
[**2123-1-3**] 07:12AM BLOOD PT-14.0* PTT-31.2 INR(PT)-1.2*
[**2123-1-4**] 06:25AM BLOOD Glucose-87 UreaN-9 Creat-1.0 Na-143 K-3.6
Cl-111* HCO3-26 AnGap-10
[**2123-1-3**] 07:12AM BLOOD CK(CPK)-61
[**2123-1-2**] 01:44AM BLOOD CK(CPK)-41
[**2123-1-3**] 07:12AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2123-1-2**] 01:44AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2123-1-4**] 06:25AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.8
[**2123-1-2**] 02:14AM BLOOD Lactate-1.0
Brief Hospital Course:
This is a [**Age over 90 **] y/o man with PMH of recurrent GI bleeding admitted
with bright and dark blood in the stool for several weeks and
hct 21.1.
.
# GI bleeding: Patient has had multiple episodes of lower GI
bleeding in the past. His current episode is likely secondary to
hemorrhoids versus diverticulosis. He did not have any
nausea/vomiting or hematemesis to suggest upper GI source though
this is technically a possibility. He was subsequently placed on
a PPI IV bid initially. There were no signs of mesenteric
ischemia on CT scan, though diverticulosis was noted.
Pt was admitted initially to the MICU for management of his
lower GI bleed. He received a total of 3 units and 2L of IV
fluids. His crit bumped from 21.1 to 28 after 3 units. He was
transferred to the floor the next day. He was guiaic negative on
admission, but did eventually pass at least 2 soft stools with
grossly bright red blood. His crits were followed [**Hospital1 **], and
remained stable. He was seen by GI, who did not think further
endoscopy would be useful for hemorrhoid/diverticular bleed, and
deferred evaluation to General Surgery for possible surgical
intervention, e.g. hemorrhoidectomy. Pt is seen by Dr. [**Last Name (STitle) 1120**] in
Colorectal Surgery. Given pt's long history of hemorrhoidal
bleeds with banding, and pt's risk factors at age [**Age over 90 **], Surgery
did not think pt would benefit from hemorrhoidectomy at this
time. Pt continued to be hemodynamically stable on day of
discharge. He will be seeing his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] this Friday for
repeat crit check, and will be following up with Dr. [**Last Name (STitle) 1120**] in
Colorectal Surgery in the beginning of [**Month (only) 404**]. He was
instructed to call his PCP or go to the ED if bleeds return or
worsen. Pt was discharged on high fiber diet and fiber
supplementation to improve bulking of the stools. Fiber
supplementation should be uptitrated to~30mg/day.
.
# EKG changes: Patient has had no complaints of chest pain but
had TWI on EKG done in ED. This likely represents sequelae of
anemia and demand ischemia given Hct of 21.1. Repeat EKG the
next a.m. showed resolution of TWI, just flattened T waves in
the lateral V leads. Cardiac enzymes were negative x3. Pt had no
additional cardiac symptoms during admission.
.
# Leukopenia: Per [**Month (only) **], this is a chronic condition for pt. WBC
ct was 2.8 on admission. WBC ct stabilized at 4.5 on day of
discharge. Pt continued to remain afebrile.
.
# Glaucoma: Pt was continued on his home Timolol and Brimonidine
eye drops.
.
# h/o gout: Stable.l Pt did not have any symptoms of gout flare,
and was continued on home Allopurinol.
.
#pruritis: Pt complained of some mild itching on back. There
weere no lesions or rashes visible. He was treated with Sarna
lotion, with improvement.
.
# FEN: Regular cardiac diet, replete lytes prn
.
# PPx: pneumoboots, bowel regimen
.
# Access: 16 g PIV and 18 g PIV
.
# CODE: DNR/DNI per patient and wife, DNR status documented in
[**Name (NI) **]
.
# COMM: With patient and wife, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 27602**]
.
# DISPO: Home, with follow-up this week with PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **], and
Dr. [**Last Name (STitle) 1120**] in Colorectal Surgery in the beginning of [**Month (only) 404**].
Medications on Admission:
MEDS:
allopurinol 150 mg daily
anusol 25 mg suppository nightly
brimonidine 0.15% one drop each eye q8h
ferrous sulfate 325 mg daily
potassium 8 meq daily
timolol 0.25% eye drops one drop each eye [**Hospital1 **]
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: [**1-21**] Tablet PO once a day.
2. Anusol-HC 25 mg Suppository Sig: One (1) dose Rectal at
bedtime.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop(s) in each eye
Ophthalmic Q8H (every 8 hours).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
5. Potassium Chloride 8 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
6. Timolol Maleate 0.25 % Drops Sig: One (1) Drop(s)in each eye
Ophthalmic [**Hospital1 **] (2 times a day).
7. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
Disp:*90 Packet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Hemodynamically stable, hematocrit stable (29.2), afebrile
Discharge Instructions:
You were admitted for management of lower GI bleeding. This was
most likely related to your hemorrhohids. You were lightheaded
and had a very low blood level. Therefore, you received IV
fluids and 3 units of blood. You were seen by GI and Colorectal
Surgery, and they did not feel that surgery was necessary at
this time. You will be following up as an outpatient with Dr.
[**Last Name (STitle) 1120**] in Colorectal Surgery. Please see your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
this Friday for follow-up of you blood levels.
.
If you experience any return of profuse bleeding,
lightheadedness, dizziness, nausea, vomiting, or have any other
.
Please continue your medications as prescribed.
- We added Psyllium as a new fiber supplement to your daily
diet. This can be bought over the counter (e.g. Metamucil.) This
should help to keep your stools soft and reduce your tendency to
bleed from straining when constipated.
Followup Instructions:
PCP
[**Name Initial (PRE) 2169**]: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2123-1-8**] 11:00
.
Colorectal Surgery
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17491**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 274**]
Date/Time:[**2123-1-27**] 9:45
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2123-1-4**]
|
[
"274.9",
"794.31",
"562.10",
"458.9",
"571.5",
"440.0",
"365.9",
"572.3",
"455.8",
"288.50",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9949, 9955
|
5647, 9035
|
282, 289
|
10014, 10075
|
3282, 5624
|
11072, 11631
|
2617, 2634
|
9300, 9926
|
9976, 9993
|
9061, 9277
|
10099, 11049
|
2649, 3263
|
228, 244
|
317, 1949
|
1971, 2221
|
2237, 2601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,538
| 170,567
|
34551
|
Discharge summary
|
report
|
Admission Date: [**2102-9-23**] Discharge Date: [**2102-9-27**]
Date of Birth: [**2077-6-11**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
Multiple lacerations of the right hand and fingers
Major Surgical or Invasive Procedure:
[**2102-9-23**]:
1. Revascularization of the ring and small finger of the right
hand.
2. Harvest of vein graft for revascularization of right and
small finger.
3. Repair of volar plate of ring PIP joint.
4. Repair of FDP tendon of ring finger.
5. Repair of FDS of long finger.
6. Repair of FDP of long finger.
7. Exploration of ulnar and radial digital arteries and nerves
of the long finger.
8. Revision amputation of small finger.
9. Use of operating microscope.
History of Present Illness:
25 year old right hand dominant man with a past medical history
significant for ADHD, prior leg staph infection now presents
with deep lacerations over the volar aspects of his middle,
ring, and small fingers. Patient states that he was
playing with a katana sword when it got stuck in a piece of
wood. He attempted to pull it out but couldn't. His hand then
slipped and he sustained lacerations over his fingers. He was
eval He smokes 1 pack per day. Patient states he takes Valium
"many times per day" and is extremely anxious. Tested positive
for marijuana, Darvocet at [**Hospital3 4298**]. EtOH level 0.203.
Past Medical History:
PMH: ADHD, anxiety
Social History:
SH: Smokes 1 1/2 packs per day. Works for a landscaping company,
tree service company. Lives at home with his parents. + EtOH.
Denies illicit drug use (although tested positive at OSH).
Family History:
Non-contributory
Physical Exam:
VS: Afebrile, VSS
Gen: NAD
CV: RRR, no murmurs
Resp: CTAB, no wheezes or crackles
Abd: Soft, mildly TTP, nondistended, +BS, incisions c/d/i
Ext: R hand in splint. R middle and ring digits with Dopplerable
pulses. Small finger amputation site c/d/i.
Pertinent Results:
[**2102-9-25**] 02:35AM BLOOD WBC-9.4 RBC-3.26* Hgb-10.6* Hct-29.7*
MCV-91 MCH-32.5* MCHC-35.7* RDW-13.2 Plt Ct-215
[**2102-9-24**] 02:28AM BLOOD WBC-13.0* RBC-3.55* Hgb-11.2* Hct-31.3*
MCV-88 MCH-31.6 MCHC-35.9* RDW-13.8 Plt Ct-237
[**2102-9-23**] 06:05AM BLOOD WBC-13.7* RBC-3.99* Hgb-12.7* Hct-35.8*
MCV-90 MCH-31.7 MCHC-35.4* RDW-13.5 Plt Ct-268
[**2102-9-23**] 12:50AM BLOOD WBC-11.1* RBC-3.90* Hgb-12.1* Hct-34.7*
MCV-89 MCH-31.1 MCHC-34.9 RDW-13.6 Plt Ct-264
[**2102-9-25**] 02:35AM BLOOD PT-12.1 PTT-37.8* INR(PT)-1.0
[**2102-9-24**] 08:06PM BLOOD PT-18.7* PTT-150* INR(PT)-1.7*
[**2102-9-24**] 12:27PM BLOOD PT-13.6* PTT-112.3* INR(PT)-1.2*
[**2102-9-24**] 05:36AM BLOOD PT-13.2 PTT-51.6* INR(PT)-1.1
[**2102-9-23**] 12:50AM BLOOD PT-13.6* PTT-29.0 INR(PT)-1.2*
[**2102-9-25**] 02:35AM BLOOD Glucose-113* UreaN-9 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-30 AnGap-10
[**2102-9-24**] 02:28AM BLOOD Glucose-120* UreaN-10 Creat-0.7 Na-138
K-3.9 Cl-101 HCO3-29 AnGap-12
[**2102-9-25**] 02:35AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9
[**2102-9-24**] 02:28AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.7
[**2102-9-23**] 12:50AM BLOOD ASA-NEG Ethanol-101* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-9-26**] 10:17PM URINE bnzodzp-POS opiates-POS
[**2102-9-23**] 12:50AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2102-9-23**] and had the following procedures done:
1. Revascularization of the ring and small finger of the right
hand.
2. Harvest of vein graft for revascularization of right and
small finger.
3. Repair of volar plate of ring PIP joint.
4. Repair of FDP tendon of ring finger.
5. Repair of FDS of long finger.
6. Repair of FDP of long finger.
7. Exploration of ulnar and radial digital arteries and nerves
of the long finger.
8. Revision amputation of small finger.
Postoperatively, the patient was admitted to the ICU for close
observation given his h/o +EtOH, marijuana, darvocet on tox
screen at OSH, and extreme anxiety. Pain service and psych were
also consulted for management of this patient. The patient was
transferred to floor status on POD#2. Patient had daily checks
of Dopplerable pulses on his right long and ring fingers. Wound
was monitored daily.
Neuro: Postop, the patient received Dilaudid IV and Tylenol PO
as well as Valium prn anxiety. He was later started on Dilaudid
PCA with adequate pain control. On POD#1, he was transitioned to
oral pain medications including Oxycontin and Neurontin as well
as Ativan prn for anxiety. Pain and psych meds were adjusted per
pain service and psych recommendations during his hospital stay.
On POD#3, there was questionable suspicion of misuse of
medications, so room search was initiated, but no other
substances/medications were found.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. Intake and output were closely
monitored.
Heme: Post-operatively, the patient was started on a heparin
drip and adjusted as necessary. Coags were routinely monitored.
Starting on POD#2, he received subcutaneous heparin daily.
ID: Post-operatively, the patient was started on IV cefazolin
until POD#3 when he was switched to oral Keflex. The patient's
temperature was closely watched for signs of infection.
At the time of discharge on POD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Escitalopram 20 mg daily, Adderal 20 mg daily
Discharge Medications:
1. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for withdrawal symptoms.
Disp:*20 Tablet(s)* Refills:*0*
2. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain for 7 days.
Disp:*28 Tablet Sustained Release 12 hr(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for breakthrough pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24
hr Sig: One (1) Capsule, Sust. Release 24 hr PO daily () as
needed for ADHD.
5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) for 7 days.
Disp:*20 Capsule(s)* Refills:*1*
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Association
Discharge Diagnosis:
Multiple lacerations of the right hand and fingers
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If 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.
* NO SMOKING. Nicotine causes vasoconstriction, which can
decrease the blood flow to the hand and compromise healing.
Followup Instructions:
Follow up in the Hand Clinic next Tuesday, [**2102-10-3**]. Please call
[**Telephone/Fax (1) 3009**] to schedule an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
Completed by:[**2102-9-27**]
|
[
"903.2",
"300.00",
"955.3",
"305.20",
"E849.8",
"305.1",
"886.0",
"314.01",
"883.2",
"903.5",
"E920.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.56",
"04.3",
"86.73",
"82.44",
"84.01"
] |
icd9pcs
|
[
[
[]
]
] |
6956, 7027
|
3402, 5828
|
365, 832
|
7122, 7129
|
2039, 3379
|
7958, 8240
|
1737, 1755
|
5924, 6933
|
7048, 7101
|
5854, 5901
|
7153, 7935
|
1770, 2020
|
275, 327
|
860, 1474
|
1496, 1517
|
1533, 1721
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,859
| 190,640
|
38769
|
Discharge summary
|
report
|
Admission Date: [**2130-3-20**] Discharge Date: [**2130-3-23**]
Date of Birth: [**2050-8-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo male with known AS and recent CHF. Seen by PCP last [**Name9 (PRE) 766**]
and started on Z-PAC for upper respiratory infection. Noted
chest
discomfort on Wednesday and brought by ambulance to [**Hospital 1263**]
Hospital. Cardiac enzymes elevated and ruled out for PE while at
[**Doctor Last Name 1263**].
Cath/CT chest done during previous work-up have revealed an
aneurysmal aortic root/asc. aorta. Referred for surgical
evaluation
Past Medical History:
aortic stenosis, ascending aortic aneurysm, paroxysmal atrial
tachycardia, hyperlipidemia, gout, NIDDM (diet-controlled), BPH,
right 5th finger contracture, pernicious anemia, chronic
diastolic heart failure, remote left rib Fxs, ? mild pulmonary
fibrosis, skin CA, bilateral cataract extractions, repair
deviated septum, removal skin CA left ear
Social History:
Family History:NC
Race:Caucasian
Last Dental Exam:one yr. ago
Lives with:wife
Occupation:retired attorney/govt.
Tobacco:never
ETOH: 2 drinks per day(highballs)
Physical Exam:
Physical Exam
Pulse: 95 Resp: 16 O2 sat RA 97%
B/P Right: 91/60 Left: 101/67
Height: 5'9" Weight: 160
General:NAD, appears sl. younger than stated age
Skin: Dry [x] intact [x] moles on chest
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: bibasilar crackles
Heart: RRR [x] Irregular [] Murmur 3/6 SEM radiates throughout
precordium to carotids
Abdomen:Soft[x] non-distended[x] non-tender[x] bowel sounds +[x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema- 1+ bil.
Varicosities: None []mild bil. spider veins
Neuro: Grossly intact, MAE [**5-10**] strengths; nonfocal exam
Pulses:
Femoral Right: 2+ (mild ecchymosis) Left:2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left : 1+
Carotid Bruit Right: ? bruit; murmur radiates to both
carotids
Pertinent Results:
CT CHEST: [**2130-3-21**]
REASON FOR EXAM: Pre-op evaluation Bentall procedure, MVR.
TECHNIQUE: Multidetector CT through the chest was acquired
without IV
contrast. 5, 1.25 mm collimation images, sagittal and coronal
reformations
were provided and reviewed.
FINDINGS: The ascending aorta measures 52 x 53 mm, is associated
with a very
dense calcification of the aortic valve. Minimal calcification
is in the
mitral annulus. There is mild cardiomegaly. Enlarged medistinal
lymph nodes
located throughout the mediastinum measure up to 12 mm in the
pretracheal
station. A conglomerate of lymph nodes in the left lower
paratracheal station
measures 15 mm. Precarinal lymph node measures 13 mm. Evaluation
of right
hilar lymphadenopathy is limited due to the lack of IV contrast.
The
subcarinal lymph nodes have small calcifications within. There
is no
pericardial effusion. Moderate right and small left layering
pleural
effusions are non-hemorrhagic. Multifocal areas of ground-glass
opacities in
both lungs are more extensive in the lingula, are associated
with small
peribronchial dense consolidation and a small area in the
posterior segment
left upper lobe and a larger area in the basal segments of the
left lower
lobe. There is minimal reticular abnormality in the periphery of
the upper
lobes bilaterally. Interstitial abnormality in the lower lobes
if present is
obscured by the pleural effusions.
This examination is not tailored for subdiaphragmatic
evaluation. Of note
there is a very dense calcification in the proximal SMA.
There are no bone findings of malignancy. Old fractures are in
left fifth and
sixth ribs. There is an old fracture in the left clavicle.
IMPRESSION: Multifocal infectious process.
Dense aortic valve calcifications.
The dilated ascending aorta measures 52 x 53 mm.
Dense calcification of the proximal SMA.
Mediastinal lymphadenopathy, likely reactive.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: WED [**2130-3-22**] 3:02 PM
Brief Hospital Course:
79 year old male who transferred from [**Doctor Last Name 1263**] Hopsital with known
aortic stenosis and CHF. Recent URI on Z-pack. admitted to the
CVICU for tacycardia. Rate control was achieved and Mr. [**Name13 (STitle) **]
was transferred to the step down unit. Chest CT was done to
evaluate aortic anatomy and multifocal infectious process was
noted. He was discharged to home on 10day course of levaquin.
Pre-op cardiac work-up was completed-carotids-benign, dental
clearance and surgical consent obtained. Scheduled for
Bentall/?MVR on [**2130-4-4**] with Dr. [**Last Name (STitle) **]. Will return on [**3-28**] to
have repeat follow CXR prior to surgery and anesthesia consent.
Medications on Admission:
Medications at home:metoprolol 25 mg [**Hospital1 **], lasix 20 mg daily,
allopurinol 300 mg daily, ASA 81 mg daily, cyanocobalamin SR
1000 mcg daily, MVI daily, nasonex 50 mcg 2 sprays each nostril
daily prn,
glucosamine chondroitin 500 mg/400 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig:
Fifteen (15) ML PO Q6H (every 6 hours) as needed for
congestion/cough.
Disp:*1 bottle* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
AS
ascending aortic aneurysm
paroxysmal atrial tachycardia
hyperlipidemia
gout
NIDDM
BPH
right 5th finger contracture
pernicious anemia
chronic diastolic heart failure
Discharge Condition:
Stable
Discharge Instructions:
Continue to use incentive spirometry until chest is clear.
Return for surgery on [**2130-4-4**]. You will be called the day
before surgery with instructions.
Followup Instructions:
Provider: [**Name10 (NameIs) 2288**] TESTING Phone:[**Telephone/Fax (1) 2289**]
Date/Time:[**2130-3-28**] 11:30
Completed by:[**2130-3-24**]
|
[
"250.00",
"441.2",
"V45.61",
"396.2",
"482.1",
"600.00",
"V10.83",
"272.4",
"718.44",
"401.9",
"411.89",
"281.0",
"274.9",
"428.0",
"428.32",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6498, 6504
|
4524, 5213
|
362, 369
|
6716, 6725
|
2336, 4501
|
6932, 7076
|
1241, 1388
|
5518, 6475
|
6525, 6695
|
5239, 5239
|
6749, 6909
|
5259, 5495
|
1403, 2317
|
282, 324
|
397, 839
|
861, 1210
|
1226, 1226
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,617
| 129,954
|
28338
|
Discharge summary
|
report
|
Admission Date: [**2194-10-24**] Discharge Date: [**2194-10-31**]
Date of Birth: [**2116-1-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
CC:[**CC Contact Info 68790**]
Major Surgical or Invasive Procedure:
Diagnostic paracentesis
Therapeutic paracentesis
Upper GI endoscopy
History of Present Illness:
78 yo Arabic only speaking M, w/a h/o GIB bleed unclear whether
upper or lower etiology, on coumadin for AF and valve
replacement who presented to son's PCP c/o SOB and fatigue. In
clinic found to have a HCT of 20.3 and told to return to ED for
further w/u. Pt [**CC Contact Info **] any hematemesis, or hematochezia but does
have some black stools from Iron supplementation. He [**CC Contact Info **] any
abdominal pain, N/V. No CP, or palpitations. Some
lightheadedness. Per son, pt has had 2 episodes of significant
"blood loss" requiring hospitalization and transfusions in
[**Hospital1 46**] starting 6 months ago with 2nd episode 1 month ago. Pt
also noticed worsening fatigue and increasing abdominal girth
starting 6 months ago as well as renal failure starting at that
time as well.
.
ED Course: Pt was HD stable, normotensive VS BP 107/41 HR 62. GI
service aware, however pt HD stable, normotensive. NG Lavage
negative, guaiac +, received 1UPRBC, and 40mEQ KCL x1.
Past Medical History:
-AF on coumadin
-AVR
-h/o GIB
-CKD
-CHF
Social History:
-From [**Last Name (un) 26580**], Arabic speaking only. Occupation: Former farmer in
[**Hospital1 46**]. Quit 30years ago, smoked 1ppd x24 years. [**Hospital1 4273**] any ETOH
or other drug use hx.
Family History:
-M: Stomach CA
-F:?
-No known liver disease in the family
Physical Exam:
VS: 96.8 104/59 55 15 100%2LNC
GEN: NAD, smiling lying comfortably in bed
HEENT: PERRL, EOMI, Anicteric sclera, MMM, OP clear
RESP: bibasilar inspiratory crackles
CV: Irreg, Nml S1,S2, [**3-31**] HSM with end systolic click loudest at
LLSB heard throughout precordium, elevated JVP ~8cm
ABD: Soft, distended, NT, +BS, +Fluid wave sign, enlarged liver,
no splenomegaly appreciated
EXT: warm, [**1-27**]+ peripheral edema, 2+ DP pulses b/l
NEURO: follows commands appropriately
Pertinent Results:
[**2194-10-23**] 02:55PM UREA N-137* CREAT-3.5* SODIUM-140
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-32 ANION GAP-15
[**2194-10-23**] 02:55PM ALT(SGPT)-11 AST(SGOT)-18 ALK PHOS-203* TOT
BILI-0.5 DIR BILI-0.3 INDIR BIL-0.2
[**2194-10-23**] 02:55PM TOT PROT-7.9 ALBUMIN-3.9 GLOBULIN-4.0
CALCIUM-9.1 CHOLEST-99
[**2194-10-23**] 02:55PM proBNP-8277*
[**2194-10-23**] 02:55PM FERRITIN-24*
[**2194-10-23**] 02:55PM TRIGLYCER-78 HDL CHOL-38 CHOL/HDL-2.6
LDL(CALC)-45
[**2194-10-23**] 02:55PM TSH-1.7
[**2194-10-23**] 02:55PM WBC-4.4 RBC-2.23* HGB-6.4* HCT-20.3* MCV-91
MCH-28.8 MCHC-31.6 RDW-15.6*
[**2194-10-23**] 02:55PM NEUTS-61.6 LYMPHS-25.5 MONOS-10.2 EOS-2.5
BASOS-0.3
[**2194-10-23**] 02:55PM PLT COUNT-245
[**2194-10-23**] 02:55PM PT-21.7* PTT-37.8* INR(PT)-2.1*
[**2194-10-23**] 02:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2194-10-23**] 02:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Echo [**2194-10-24**]:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *7.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *7.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 5.3 cm
Left Ventricle - Fractional Shortening: *0.17 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 25% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *2.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 2.1 m/sec
Mitral Valve - E Wave Deceleration Time: 247 msec
TR Gradient (+ RA = PASP): *33 to 40 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.
LEFT VENTRICLE: Moderately dilated LV cavity. Severe global LV
hypokinesis.
Severely depressed LVEF.
RIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV
free wall
hypokinesis.
AORTA: Normal aortic root diameter. Moderately dilated ascending
aorta.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well
seated, normal
leaflet/disc motion and transvalvular gradients.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Severe (4+) MR.
TRICUSPID VALVE: Severe [4+] TR. Moderate PA systolic
hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is markedly dilated. The right atrium is
markedly dilated.
2. The left ventricular cavity is moderately dilated. There is
severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is
severely depressed.
3. The right ventricular cavity is markedly dilated. There is
severe global
right ventricular free wall hypokinesis.
4. The ascending aorta is moderately dilated.
5. A bileaflet aortic valve prosthesis is present. The aortic
prosthesis
appears well seated, with normal leaflet motion and
transvalvular gradients.
5. The mitral valve leaflets are mildly thickened. Severe (4+)
mitral
regurgitation is seen.
6. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension.
Renal ultrasound [**2194-10-25**]:
IMPRESSION: No interval change in appearance of the kidneys in
comparison to the exam from one day prior:
1. No hydronephrosis.
2. Stable bilateral renal cysts.
3. Ascites.
Brief Hospital Course:
Mr. [**Known lastname 68791**] is a 78 yo M w/heart failure, AF on coumadin, Ao valve
replacement, and CKD who presented with SOB, fatigue, anemia and
ascites.
GI
1. GI bleed: Mr. [**Known lastname 68791**] had a hct of 20.3 at presentation with
black stool that were guaiac positive. He denied hematemesis or
hematochesia. NG lavage was negative and he remained
hemodynamically stable. EGD showed an AVM in his stomach that
was successfully cauterized. His hct was repleted with 7 units
of pRBC's total and he retained a stable Hct of ~30. The patient
was kept of a PPI during his hospital course for his GI bleed.
2. Ascites: Mr. [**Known lastname 68791**] presented with an expanding abdomen over a
two week period. Diagnostic tap of the peritoneal fluid was
suggestive of cardiac ascites with a serum ascites albumin
gradient > 1.1 and total protein > 2.5. This is likely secondary
to his HF and severe TR. A therapeutic tap withdrew 4L of
fluid. Abd ultrasound showed nodular echotexture of the liver
with irregular contour suggestive of cirrhosis. LFT's were
within normal limits and there was appropriate synthetic
function with a serum albumin of 3.7. Hepatitis panel was
positive for hep A antibodies and negative for hep B and hep C.
Hep C PCR is still pending.
.
CARDIAC:
1. Heart failure: Mr. [**Known lastname 68791**] had an aortic valve replacement in
[**2181**], and was diagnosed with heart failure six years ago in
[**Hospital1 46**]. He presents with increasing SOB and fatigue, but [**Hospital1 **]
orthopnea and PND. He claims to have an exercise tolerance of
walking greater than half a mile. We obtained a TTE which
revealed an EF of 25% with 4+ TR and MR and 4 chamber dilation.
Mr. [**Known lastname 68791**] [**Last Name (Titles) **] ever having a heart attack and he had a cardiac
cath in [**2181**] that showed clean coronaries. His dilated
cardiomyopathy is presumed to be non-ischemic in nature. The
patient was fluid overloaded on presentation with bilateral
crackles up a third of his lung fields and pulmonary edema on
CXR. The patient was gently diuresed over his hospital course
and was breathing and sating well on RA with clear lung fields
prior to discharge. He was started on Toprol XL 12.5 qd and
lisinopril 5mg qd for his heart failure. The patient did not
tolerate a higher dose of beta-blocker as he became bradycardic
with asystolic periods as long as 2.45 seconds before being
broken by a ventricular escape beat.
2. Arrhythmia: Patient was in Afib with several runs of
non-sustained Vtach. The patient was started on metoprolol
12.5mg PO BID for rate control. While on metoprolol, he
experienced several episodes of asystole lasting as long as 2.45
seconds followed by ventricular escape beats. His metoprolol
dose was cut to Toprol XL 12.5mg qd.
3. Valves: The patient is s/p AVR in [**2181**]. His TTE showed 4+ TR
and MR likely due to dilation of the heart. The patient's
coumadin was held after being admitted for a GI bleed. His INR
drifted down to 1.6 after his GI studies and his coumadin was
restarted with a heparin bridge. His INR at discharge was 1.9.
.
RENAL
1. ARF: The patient was in acute renal failure with a Cr of 4.1
at admission. This was thought to be pre-renal in the setting of
his heart failure. With gentle diuresis his Cr trended down to
2.3 on the day of discharge. We did not have a baseline Cr, but
he has chronic renal failure by history.
Medications on Admission:
MEDS From Home:
-Nexium
-Lasix
-Dig
-Iron
-Folic Acid
-Coumadin
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Congestive heart failure
Upper GI bleeding
Acute renal failure
.
Secondary:
-AF on coumadin
-AVR
-h/o GIB
-CKD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for shortness of breath and
fluid overload in your abdomen due to heart failure. You were
also found to have a very low hematocrit level due to
gastrointestinal bleed. You were transfused with blood and had a
upper GI endoscopy done which showed one bleeding site that was
cauterized. Your kidney function improved after blood
transfusions. You were diuresed with lasix to remove excess
fluid from lungs and abdomen. A paracentesis was done to further
remove extra fluid from the abdomen. The culture from the fluid
was still pending at the time of discharge, and your PCP can
follow up on this result.
.
Regarding the atrial fibrillation, your coumadin was temporarily
held for evaluation of GI bleed and you will need your INR
checked by the VNA service regularly to ensure it remains within
a therapeutic range.
.
Blood pressure medications prior to admission were modified due
to low heart rate. After discharge, you should take all of your
medications as prescribed and followup with your outpatient
cardiologist for further medical management.
.
Please return to the ED or call your PCP if you experience
shortness of breath, chest pain, increase in abdomen size, or
lower extremity swelling.
.
Maintain a low sodium, cardiac healthy diet.
Followup Instructions:
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS
Date/Time:[**2194-11-11**] 12:30
.
Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 10485**], MD Phone:[**Telephone/Fax (1) 2986**]
Date/Time:[**2194-11-11**] 12:30
.
You have an appointment with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in the heart
failure clinic on [**11-17**] at 9am. This is on the [**Location (un) 436**]
of the [**Hospital Ward Name 23**] Building. You may call [**Telephone/Fax (1) 3512**] with any
questions or if you need to reschedule.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2194-11-17**] 9:00
You have an appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 4922**] on
[**11-20**] at 2:00pm. You may call his office at [**Telephone/Fax (1) 2936**]
with any questions or to reschedule.
|
[
"428.20",
"280.9",
"425.4",
"424.0",
"427.31",
"V58.61",
"593.2",
"537.83",
"276.8",
"V43.3",
"594.9",
"427.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"44.43",
"99.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10071, 10129
|
5877, 9297
|
347, 417
|
10293, 10302
|
2285, 5854
|
11630, 12635
|
1715, 1774
|
9411, 10048
|
10150, 10272
|
9323, 9388
|
10326, 11607
|
1789, 2266
|
278, 309
|
445, 1421
|
1443, 1484
|
1500, 1699
|
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