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16,976
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46833
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Discharge summary
|
report
|
Admission Date: [**2168-4-27**] Discharge Date: [**2168-5-2**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon / Keppra
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
52 year old woman with cirrhosis secondary to HepC and alcohol,
GI bleed secondary to portal gastropathy s/p TIPS, recurrent
hepatic encephalopathy who is referred after being found
lethargic and responsive only to sternal rub.
.
Of note she was just discharged on [**2168-4-22**] following an
admission for hepatic encephalopathy. During that admission her
TIPS was found to be patent on doppler.
.
Earlier today she was noted at her [**Hospital1 1501**] to be lethargic and
responsive to noxious stimuli. At baseline she is confused and
with delusional thought content. Her vitals prior to transfer
wer unremarkable.
.
Upon arrival to the ED she was awake, but with her eyes closed
responding to painful stimuli with yelling. Her initial vital
signs were 99.4 62 104/61 14 100%RA. IV lines were placed. A
foley was placed. She was intubated for airway protection with a
#7.0 ETT with etomidate and rocuronium. An OGT was placed and
both ETT and OGT were confirmed in good position by CXR. She
was sedated with propofol. Post intubated she was hypertensive
to 213/130 but normalized without directed antihypertensives.
She also received 1L of NS, kayexalete/glucose/insulin (K 6.6),
and one dose of lactulose.
Past Medical History:
1) Iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids, s/p TIPS; also
w/ known portal gastropathy
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duodenal polyps and duodenitis
6) MGUS
7) ?Etoh/ HCV cirrhosis followed in Liver Center
8) Psychotic disorder
9) polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) ?? h/o Complex partial seizures
12) subcutaneous variceal rupture s/p hematoma exploration in
LLQ
13) Chronic kidney disease (baseline Cr ~1.4)
Social History:
History of tobacco and EtOH abuse. She is originally from
[**State 3908**], and changed her name when she became a practicing
Muslim. She worked as an administrative assistant when she was
younger, but is now on SSDI (for schizophrenia and seizure
disorder, per pt, both now quiescent).
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
Afebrile, P77, BP 134/70, R 13, 100% RA
Gen: intubated and sedated
HEENT: ETT in place. Atraumatic. MMM. PERRLA. JVP flat
Chest: clear anterior and laterally
CV: non-displaced PMI. RRR no m/r/g
Abd: soft flat no fluid wave. Active bowel sounds. LLQ 4x3cm
open superficial wound
Ext: marked muscle wasting. 2+ radial bilat and 2+ DP bilat. No
edema
Neuro: intubated and sedated
Pertinent Results:
Admission labs:
[**2168-4-26**] 06:28PM WBC-4.5 RBC-3.36* HGB-11.0* HCT-32.7* MCV-98
MCH-32.9* MCHC-33.7 RDW-15.5
[**2168-4-26**] 06:28PM PLT COUNT-195
[**2168-4-26**] 06:28PM GLUCOSE-92 UREA N-48* CREAT-1.8* SODIUM-136
POTASSIUM-8.1* CHLORIDE-105 TOTAL CO2-20* ANION GAP-19
[**2168-4-26**] 06:28PM PT-15.7* PTT-49.2* INR(PT)-1.4*
.
Discharge labs:
[**2168-5-1**] 09:15AM BLOOD WBC-3.8* RBC-3.66* Hgb-11.5* Hct-36.8
MCV-100* MCH-31.5 MCHC-31.4 RDW-14.6 Plt Ct-133*
[**2168-5-1**] 09:15AM BLOOD PT-16.0* INR(PT)-1.4*
[**2168-5-1**] 09:15AM BLOOD Glucose-100 UreaN-21* Creat-1.3* Na-138
K-4.7 Cl-111* HCO3-15* AnGap-17
[**2168-5-1**] 09:15AM BLOOD Calcium-10.3* Phos-4.2 Mg-1.8
[**2168-5-1**] 09:15AM BLOOD ALT-32 AST-35 AlkPhos-104 TotBili-1.7*
.
Studies:
CT HEAD W/O CONTRAST [**2168-4-26**]
IMPRESSION: No evidence of acute intracranial hemorrhage, no
change from prior studies.
.
CHEST (PORTABLE AP) [**2168-4-26**]
FINDINGS: Portable AP upright chest radiograph is obtained. Low
lung volumes limits evaluation. The lungs appear clear
bilaterally, demonstrate no evidence of pneumonia or CHF. No
pleural effusions or evidence of pneumothorax is seen.
Cardiomediastinal silhouette is normal. No pneumothorax is seen.
Visualized osseous structures are intact. A stent is noted in
the right upper quadrant compatible with TIPS.
.
ECG Study Date of [**2168-4-26**]
Rate PR QRS QT/QTc P QRS T
69 182 86 424/439 70 -9 62
Sinus rhythm. Consider left atrial abnormality. Normal ECG.
Since previous tracing of [**2168-4-20**], increased voltage.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2168-4-27**]
IMPRESSION:
1. Patent TIPS with appropriate velocities throughout.
2. No evidence for ascites.
3. Small amount of sludge in the gallbladder.
Brief Hospital Course:
62 year old woman with cirrhosis c/b portal gastropathy s/p TIPS
with recurrent hepatic encephalopathy presenting with altered
mental status requiring intubation overnight for airway
protection.
.
1. Hepatic encephalopathy: Pt's altered mental status is
likely [**2-13**] hepatic encephalopathy as pt improved with increased
lactulose. She required intubation overnight for airway
protection. There is no clear precipitant. There is no clear
evidence of infection though patient did have a fever in the
ICU; this fever may have been due to aspiration peri-intubation.
She had a RUQ that was negative for acute pathology, and she
had no ascites to tap. Urine culture was negative. BCxs have
no growth to date. Sputum culture did grow moderate MRSA,
sparse GNRs; however, pt is known to be colonized with MRSA and
has no other s/sxs to suggest infection. CXRs have been
unremarkable. She tested negative for influenza and C. diff as
well. Her zyprexa and keppra were held on admission and added
back as the pt's mental status returned to baseline, and she
tolerated them well. She was continued on lactulose &
rifaximin.
.
2. Hepatitis C virus cirrhosis: Her LFTs and coags remained at
baseline. Pt was continued on lactulose/rifaximin for hepatic
encephalopathy. Her Lasix was held on admission due to acute on
chronic renal failure.
.
3. Acute on chronic kidney disease: Pt's baseline creatinine is
1.1-1.4. Pt was likely volume depleted [**2-13**] poor po intake on
diuretics. Her lasix was held on admission and her creatinine
returned to baseline. She will follow up with Dr. [**Last Name (STitle) 497**] to
determine whether she should continue on diuretics.
.
4. Hypertension: Pt's metoprolol was titrated up to Toprol XL
200 mg daily. SBP at discharge ranged from 110-140.
.
5. Anemia: This is multifactorial due to kidney disease, liver
disease, and chronic blood loss. She was continued on iron
supplements. She will resume Aranesp as an outpatient.
.
6. Psychosis: Patient was continued on her home regimen of
zyprexa.
.
7. Seizure disorder: Pt was restarted on her keppra at lower
dose given her liver/kidney disease. She had no seizures while
in house.
.
8. Code status: FULL
Medications on Admission:
keppra 750 mg [**Hospital1 **]
zyprexa 5mg [**Hospital1 **]
zyprexa 5 mg q6prn
metoprolol 50 q8hours
acetaminophen 325-650 mg q4:prn
Milk of Magnesium prn
bisacodyl 10 mg PR daily:prn
Maalox 30 mL q4:prn
pantoprazole 40 mg daily
aranesp 25 mcg qMonday last dose [**2168-4-18**]
Klor-con 20 mEq daily
lasix 40 mg daily
ferrous sulfate 325 mg daily
lactulose
ursodiol 300 mg q12
multivitamin daily
lactulose 30 mL QID
rifaximin 600 mg [**Hospital1 **]
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Sixty (60) ML PO TID (3
times a day): Please titrate to [**4-17**] bowel movements a day.
2. Rifaximin 200 mg Tablet [**Month/Day (3) **]: Three (3) Tablet PO BID (2 times
a day).
3. Ursodiol 300 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO BID (2 times
a day).
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Month/Day (3) **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Levetiracetam 500 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2
times a day).
6. Olanzapine 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO twice a day.
7. Olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Day (3) **]: One (1) Tablet,
Rapid Dissolve PO Q6H (every 6 hours) as needed for agitation.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
10. Hexavitamin Tablet [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily).
11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: 325-650 PO Q8H
(every 8 hours) as needed for fever or pain: Please limit to 2
gm per day.
12. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed.
13. Aranesp (Polysorbate) 25 mcg/0.42 mL Syringe [**Last Name (STitle) **]: One (1)
Injection once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Hepatic encephalopathy
.
Secondary:
Hepatitis C virus Cirrhosis
Acute on chronic kidney disease
Seizure disorder
Hypertension
Multifactorial anemia
Discharge Condition:
Stable, alert, not oriented
Discharge Instructions:
You were admitted for decreased responsiveness. You required a
breathing tube for one night. Your mental status has improved
with increases in your lactulose. Please make sure you take
enough lactulose to make [**4-17**] bowel movements a day.
.
Please take your medications as directed.
.
If you develop lightheadedness, chest discomfort, shortness of
breath, abdominal pain, blood in your stools, or decreased
responsiveness, please call your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 99380**] at [**Telephone/Fax (1) 99381**] or Dr. [**Last Name (STitle) 497**] at ([**Telephone/Fax (1) 1582**] or go to
the Emergency Department.
Followup Instructions:
Please keep the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2168-5-13**] 11:20
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17,181
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25022
|
Discharge summary
|
report
|
Admission Date: [**2175-3-13**] Discharge Date: [**2175-3-24**]
Date of Birth: [**2098-12-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Milk
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
vomiting, diarrhea
Major Surgical or Invasive Procedure:
[**First Name3 (LF) 4338**] L spine
History of Present Illness:
76 year-old woman discharged [**2175-1-18**] after prolonged history of
L4-L5 osteomyletis/discitis (week 10 of 12 of vanc), psoas
myositis, viridans strep bacteremia, and multiple other medical
issues who presents from her nursing home with diarrhea and
vomiting x 3 days.
.
In the [**Name (NI) **], pt had episodes of hypotension (SBP down to 60's),
and was given 7 L NS. She was found to have positive UA,
elevated Cr of 2.8 (up to 3.3 at NH, baseline 0.9), and WBC
count of 16.3. She was placed on levophed through a PICC line
(pt refused central line). An arterial line was attempted but
was unsuccessful in the ED. SBP improved to 110 after IVF and
pressors. She received dexamethasone 10mg IV, and had a 250mcg
[**Last Name (un) 104**] stim test. CT scan showed possible L4-L5 osteomyelitis and
aspiration pneumonia. Neurosurg was consulted, who did not
recommend surgical intervention for osteo. In the ED, she
received ceftaz, flagyl, vanco, as well as oxycodone and IV
dilaudid.
.
Pt reports last fever was "1 month ago." She was afebrile in the
ED. She currently denies CP, SOB, N/V, diarrhea. She only c/o
chronic back and knee pain.
Past Medical History:
- L4-L5 osteomyletis/discitis, psoas myositis with Strep
Viridans Bacteremia admitted [**Date range (1) 62832**] at [**Hospital1 18**], then again
[**Date range (1) 20674**] with fever. Followed in [**Hospital **] clinic, vanc dose recently
increased.
- Anemia--seen by Dr. [**First Name (STitle) 10643**] [**1-10**]--thought to be
multi-factorial including possibly hemorroidal bleeding (hx of
guaiac pos stools)
- Chronic Pain
- h/o benzo dependence
- HTN
- pAfib--off coumadin since recent [**12-21**] admit pending anemia
work-up and re-eval by PCP, [**Name10 (NameIs) **] amiodarone
- COPD
- PVD: aortic occlusion s/p R ax-bifem ([**2173-10-12**]) c/b fluid
collection s/p R groin exploration ([**2173-10-22**]) and bilateral groin
hematomas
- h/o AAA
- depression
- dementia
- h/o MRSA
- s/p laminectomy ([**4-21**] at OSH)
- h/o CHF: TEE [**2174-12-28**] showed no vegetation, EF>55%, multiple
aortic atheromas, 1+ AR, 1+ MR
Social History:
No current smoking. Prior 75 pack year hx, occasional alcohol,
no drug use. Lives in [**Hospital3 **] at Life Care center at
[**Hospital3 **]. Her HCP is [**Name (NI) 11556**] [**Name (NI) **] (friend) at [**0-0-**].
She also has two children who are supportive.
Family History:
Two brothers died with COPD. One brother had alcoholism. Both
parents had CAD.
Physical Exam:
Vitals: T 97.7 BP 123/54 HR 78 RR 18 O2 100% 2L NC
Gen: NAD, breathing comfortably
HEENT: PERRL. OP clear.
Neck: JVD @ 6cm
Cardio: RRR, nl S1S2, [**3-21**] sys murmur @ RUSB
Resp: scattered exp wheeze, otherwise clear
Abd: soft, nt, nd, +BS
Ext: warm, no edema
Neuro: A&Ox3, moves all 4 ext
Rectal: guaiac negative (per ED)
Pertinent Results:
[**2175-3-13**] 08:15PM WBC-16.3*# RBC-3.80* HGB-11.5* HCT-31.9*
MCV-84 MCH-30.4 MCHC-36.2* RDW-16.7*
[**2175-3-13**] 08:15PM VANCO-23.9*
[**2175-3-13**] 08:15PM CALCIUM-9.9 PHOSPHATE-3.8 MAGNESIUM-1.5*
[**2175-3-13**] 08:15PM LIPASE-17
[**2175-3-13**] 08:15PM ALT(SGPT)-23 AST(SGOT)-22 ALK PHOS-81
AMYLASE-32 TOT BILI-0.2
[**2175-3-13**] 08:15PM UREA N-84* CREAT-2.8*#
[**2175-3-13**] 08:19PM GLUCOSE-92 NA+-129* K+-6.3* CL--106 TCO2-14*
[**2175-3-13**] 08:30PM URINE AMORPH-FEW
[**2175-3-13**] 08:30PM URINE RBC-[**3-20**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**6-25**] TRANS EPI-[**3-20**]
[**2175-3-13**] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2175-3-13**] 08:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2175-3-13**] 10:49PM LACTATE-0.48*
.
[**2175-3-13**] 10:50 pm BLOOD CULTURE
ANAEROBIC BOTTLE (Final [**2175-3-18**]): STAPHYLOCOCCUS, COAGULASE
NEGATIVE.
.
C-diff (-) x 3
.
CT ABDOMEN W/O CONTRAST [**2175-3-14**] 2:21 AM
IMPRESSION:
1. Chronic collection over inferior aspect of axillobifemoral
graft just prior to crossover of femorals measuring 5.8 x 4.6 x
10.1 cm.
2. Significant endplate changes with erosive changes noted at
L4-L5 which may represent an osteomyelitis.
3. Increased interstitial markings with tree-in-[**Male First Name (un) 239**] pattern
which may represent infection and possible aspiration pneumonia.
4. Coil within uterus: removal should be considered.
.
Portable AP [**3-14**]
No focal consolidation, however, there is subtle, ill-defined
asymmetric airspace opacity in the left lower lobe, better
appreciated on the prior abdominal CT, which may represent early
infection, inflammation, and/or aspiration.
.
Portable AP [**3-18**]
The heart and mediastinum are normal. No acute infiltrates are
present. There is a prominent interstitial [**Doctor Last Name 5926**] again seen
suggesting some chronic interstitial process.
.
MR L SPINE W/O CONTRAST [**2175-3-21**] 10:48 AM
Grossly limited study due to extensive patient motion and early
termination prior to gadolinium administration. Given these
limitations, there is no gross change in findings at L4-L5 from
[**2-15**] exam. Suggest re- examination after sedation to
exclude residual infection at this site.
.
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2175-3-23**]
Pre lim read, no significant change in severe osteo, L4-L5
region Decreased inflammation adjacent to psoas muscle.
Brief Hospital Course:
76 yo f with chronic L4-L5 osteo/discitis, COPD, HTN, PVD, who
presented with continued osteomyeltis, ARF, hypotension,
diarrhea, and vomiting.
.
#) Hypotension/sepsis: Pt had several sources of infection that
could cause hypotension including worsening L-spine
osteomyelitis, line infection, axillary bifem graft fluid
collection, aspiration pneumonia. However, suspected hypotension
related to severe dehydraton [**2-17**] gastroenteritis. Blood cultures
from [**3-13**] grew 1/4 bottles coag neg staph. She was aggressively
volume repleted. Pt initially required pressors (levophed), but
this was weaned to off prior to transfer to the floor. Her SBP's
remained in the 80's-90's, but she was mentating well and had
excellent [**Last Name (LF) **], [**First Name3 (LF) **] it was thought that the BP readings may be
erroneous. CT scan showed intrauterine coil, likely
representing IUD seen on past XR's. During prior admission,
OB-GYN was consulted and stated that given that the string is no
longer palpable, removal would require more invasive attempts
usually performed under anesthesia - therefore rec'd leaving it
in. Was left in. Seroma, psoas myositis stable. Pt was initially
treated with cefepime, linezolid, and flagyl, but this was
changed to vanc prior to transfer to floor, as it was believed
pt did not have active bacterial infecion other than chronic
osteo. Pt's PICC line was pulled given positive blood cultures
(although this was possibly contamination). Not replaced. Pt
afebrile with no diarrhea on floor. C-diff (-) x 3. [**Location (un) 27292**]
virus negative. [**Location (un) 4338**] L spine repeated to assess L4-L5
osteo/discitis. [**3-21**] [**Month/Day (4) 4338**] with movement poor quality film.
Repeated [**3-23**] with no change in osteo, but no evidence of abscess
and some improvement in inflammatory changes adjacent to psoas
muscle.
.
#) L4-L5 osteomyelitis: chronic L4-L5 osteo/discitis. neurosurg
saw pt in ED, recommended non-surgical management. Maintained on
Vancomycin IV throughout admission. Total 12 week course, pt
started [**2174-12-28**]. [**3-21**] [**Month/Day (4) 4338**] with movement poor quality film.
Repeated [**3-23**] with no change in osteo, but no evidence of abscess
and some improvement in inflammatory changes adjacent to psoas
muscle. At discharge to nursing home, no further positive blood
cultures, osteo stable, vancomycin stopped after total 12 week
course of Abx. DC'd on cephalexin given fem grafts, previous pos
cultures for strep viridans [**2175-12-22**].
.
#) Infiltrate on CT scan: pneumonia unlikely as pt afebrile with
no 02 req. Legionella urinary antigen negative. Has baseline
component of COPD. Pt improved breathing well with nebulizers.
Aspiration precautions. No evidence of pneumonic process.
.
#) UTI: dirty UA on admission (with epi's also). Repeated UA/cx,
negative, yeast growth thoughw ith foley.
.
#) Diarrhea/vomiting: possibly due to viral gastroenteritis. No
emesis since admission but diarrhea persistent until 4 days
prior to discharge. Norovirus assay negative. Stool cx's no
growth. C-diff negative x 3. Flagyl on admission, stopped after
third stool sample negative for c-diff.
.
#) ARF: Resolved. Pt with Cr up to 2.8 on admission (baseline
0.9). Resolved after aggressive fluid repletion suggesting
pre-renal etiology. likely [**2-17**] volume loss from
vomiting/diarrhea and less likely sepsis.Improved to 1.6 after
aggressive IVF, so etiology likely pre-renal. NO hydro on CT
abd. Now at baseline creatinine 1.
.
#) pAfib: pt no longer on coumadin due to anemia and hx of
guaiac pos stools. Currently in NSR on amio. Continued
amiodarone.
.
#) HTN: held lisinopril given recently on pressure, BP still
low-normal. To be restarted by PCP as outpatient.
.
#) PVD: hx of ax-bifem graft with known post-surgical fluid
collection (likely chronic). Continued aspirin. Given strep
viridans bacteremia and grafts, patient to be discharged on
Cephalexin 500 mg daily.
.
#) Back pain: likely from chronic osteo. Oxycontin with prn
oxycodone per home regimen
.
#) COPD: stable. Continued alb/atrovent nebs prn.
.
#) Anemia: recent baseline mid-high 20's. Stable. Prior iron
studies c/w ACD.
.
#)Rash: Uritcarial rash developed 2 days prior to discharge.
Considered related to Abx. Fexofenadine. DC'd Vanc. To follow up
resolution in nursing home. Reports allergy to penicillin but
per records able to tolerate cephalasporins. Will assess for
rash on Keflex.
.
#) Code: DNR/DNI (confirmed with pt)
#) Comm: HCP (friend) [**Name (NI) 11556**] [**Name (NI) **] [**0-0-**].
Medications on Admission:
Vancomycin 500mg IV qd (week 10 of 12)
Cymbalta 30mg QOD (finished taper to off yesterday)
Celexa 10mg qd (started [**3-13**])
Benadryl 25mg q6h prn
Docusate Sodium 100 mg [**Hospital1 **]
Senna [**Hospital1 **] prn
Dulcolax 10mg pr prn
compazine 10mg po q12h prn
Serax 10mg po q8h prn anxiety
Serax 10mg po bid
Lactobacillus 2 tabs [**Hospital1 **] (to be finished [**3-15**])
Atorvastatin 20 mg qd
Prinivil 20mg qd
Amiodarone 200 mg qd
Oxycontin 20mg q12h
Albuterol nebs q6h prn
Ipratropium nebs q6h prn
Aspirin 81 mg qd
Oxycodone 5 mg q4h prn
Acetaminophen 500mg q6h
Trazodone 50 mg qhs prn
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
10. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
12. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for anxiety: please give as previously had
for break through anxiety.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
16. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
18. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
lifecare [**Hospital3 **]
Discharge Diagnosis:
Primary-
sepsis
Acute renal failure
Diarrhea
L4-L5 discitis/osteomyelitis
.
Secondary:
psoas myositis with Strep Viridans Bacteremia admitted
[**Date range (1) 62832**] at [**Hospital1 18**], then again [**Date range (1) 20674**] with fever. Followed
in [**Hospital **] clinic, vanc dose recently increased.
- Anemia--seen by Dr. [**First Name (STitle) 10643**] [**1-10**]--thought to be
multi-factorial including possibly hemorroidal bleeding (hx of
guaiac pos stools)
- Chronic Pain
- h/o benzo dependence
- HTN
- pAfib--off coumadin since recent [**12-21**] admit pending anemia
work-up and re-eval by PCP, [**Name10 (NameIs) **] amiodarone
- COPD
- PVD: aortic occlusion s/p R ax-bifem ([**2173-10-12**]) c/b fluid
collection s/p R groin exploration ([**2173-10-22**]) and bilateral groin
hematomas
- h/o AAA
- depression
- dementia
- h/o MRSA
- s/p laminectomy ([**4-21**] at OSH)
- h/o CHF: TEE [**2174-12-28**] showed no vegetation, EF>55%, multiple
aortic atheromas, 1+ AR, 1+ MR
Discharge Condition:
stable
Discharge Instructions:
You were admitted with diarrhea, vomiting, acute renal failure,
sepsis. Improved with antibiotics and fluids. You had an [**Month/Day/Year 4338**] of
your L-spine which demonstrated improvement in your L4-L5
osteo/discitis.
You have been taken off vancomycin and are to take cephalexin
500 mg life long given grafts in place and hx of bacteremia.
-Please discontinue vancomycin
-Please hold on your prinivil given low blood pressure and
restart as per your primary care doctor.
-Please take new antibiotic cephalexin 500 mg daily.
-Please take Fexofenadine as directed for rash, until told to
stop by PCP.
[**Name10 (NameIs) 27231**] primary care doctor will visit you in the nursing home
regularly.
-Please attend Infectious disease appointment [**4-20**] as
stated below.
-Please return to the hospital if you are experiencing fever,
severe back pain, abdominal pain, nausea, vomiting, diarrhea,
fainting, confusion or any other symptoms concerning to you.
Please contact Dr. [**First Name (STitle) **] if worsening back pain, fever concerning
for worsening osteo.
Followup Instructions:
Dr. [**Last Name (STitle) **] was informed. He will visit you regularly in the
nursing home.
.
Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **]. Infectious disease. [**Telephone/Fax (1) 457**]. Please call
to confirm.
Date/Time: [**2175-4-20**] 10 AM.
.
[**Telephone/Fax (2) 18509**]Provider: [**Last Name (LF) **],[**First Name3 (LF) **] M. NEUROSURGERY WEST
Date/Time:[**2175-3-28**] 11:15
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] [**Name11 (NameIs) **] LMOB (NHB) Date/Time:[**2175-4-25**]
2:00
.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2175-4-25**] 3:00
.
|
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47,614
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9672
|
Discharge summary
|
report
|
Admission Date: [**2127-3-4**] Discharge Date: [**2127-3-19**]
Date of Birth: [**2084-12-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
found down, unresponsive
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
42 F (name is [**Name (NI) 402**] [**Name (NI) **]) w/ no known PMHx, on no known
medications, BIBA EMS to OSH ([**Location (un) **]-[**Doctor First Name **]) after being found
down in her apartment. Per report, pt has a neighbour who checks
on her from time to time, and as she did not answer the door
today ([**3-3**] at 08:00), neighbour became concerned and called
911.
.
EMS found her unresponsive, lying face down in pool of dark
black bloody emesis in an unkempt household with empty bottle of
methadone next to her. Per report she was barely responsive and
barely breathing. She was given Narcan without response.
Intubation was attempted in the field but was unsuccessful. She
was ambu-bagged the entire way to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital ED.
There she was hypotensive w/ SBPs to 60s and tachycardic to
140s. She was intubated for airway protection with etomidate/
succinylcholine as she continued to cough up copious amounts of
coffee-ground emesis. Stools were also noted to be guaiac
positive and brown. Pt was noted to be febrile up to 102 F and
had CXR concerning for R-sided aspiration PNA, for which
treatment with vanc/zosyn was initiated.
.
She was medflighted to [**Hospital1 18**] ED for tertiary care
In the [**Name (NI) **] pt was given 200ml NS w/ levophed, 250 D5W w/ 80mg
protonix, 500ml NS w/ vancomycin, and additional 2.5 L NS.
.
Initial ABG: 7.09/73/76
ABG upon intubation 7.17/ 64/57 on AC 500x16 PEEP 5 FiO2 100%
Past Medical History:
- Polysubstance abuse, opioid dependence
- Hep C, Cirrhosis, last VL [**6-27**] - 683K, unknown genotype.
- Knee arthritis b/l
Social History:
Takes care of her elderly parents with whom she lives.
Cigarettes: [ ] never [ ] ex-smoker [X] [**1-19**] cigarettes per
day
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs: none
Occupation: unemployed
Marital Status: [ ] Married [X] Single
Lives: [ ] Alone [X] w/ family [ ] Other:
Family History:
Diverticulitis and colon surgery in mother. [**Name (NI) **] father has
dementia. One of her nieces has gall bladder disease.
Physical Exam:
ON ADMISSION:
VS: afebrile HR 110s BP 106/60, SaO2 100% on AC 500x16, PEEP 5,
FiO2 100%, Ht 5'8 Wt 113 kg
GEN: ill-appearing obese caucasian F intubated, sedated but
opening eyes to commands
HEENT: PERRLA, no scleral icterus, marked B/L periorbital edema
CV: tachycardic, no murmurs appreciated
LUNGS: coarse ventilated BS anteriorly
ABD: +BS soft does not seem tender
EXT: b/l LE edema, anasarca
NEURO: intubated, sedated but responsive to eye opening
At discharge:
VS: SpO2 93% on 3L NC and 70% tent mask or one 5L NC alone at
times
GEN: awake, alert F in NAD, answering questions appropriately,
fully oriented
HEENT: no periorbital edema
CV: slightly fast but regular, II/VI holosystolic murmur
LUNGS: scattered insp crackles, worst at R apex and L base, no
wheezes
ABD: +BS, soft, NT, ND
EXT: 2+ pitting edema b/l to below knee
Pertinent Results:
ADMISSION LABS:
[**2127-3-4**] 02:15AM WBC-8.4 RBC-3.45* HGB-11.8* HCT-35.3*
MCV-102* MCH-34.1* MCHC-33.3 RDW-15.4
[**2127-3-4**] 02:15AM NEUTS-77* BANDS-4 LYMPHS-9* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2127-3-4**] 02:15AM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2127-3-4**] 02:15AM PLT COUNT-103*
[**2127-3-4**] 02:15AM PT-20.9* PTT-41.6* INR(PT)-1.9*
[**2127-3-4**] 02:15AM GLUCOSE-79 UREA N-13 CREAT-0.9 SODIUM-143
POTASSIUM-3.0* CHLORIDE-110* TOTAL CO2-21* ANION GAP-15
[**2127-3-4**] 02:15AM CK(CPK)-1646*
[**2127-3-4**] 02:15AM CK-MB-31* MB INDX-1.9
[**2127-3-4**] 02:15AM cTropnT-0.60*
[**2127-3-4**] 02:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-3-4**] 02:15AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2127-3-4**] 02:21AM TYPE-ART PO2-76* PCO2-73* PH-7.09* TOTAL
CO2-23 BASE XS--9 COMMENTS-GREEN TOP
[**2127-3-4**] 02:21AM GLUCOSE-73 LACTATE-6.7* K+-3.1*
Pertinent Labs:
[**2127-3-14**] 05:02AM BLOOD VitB12-1774* Folate-16.0
[**2127-3-4**] 05:40AM BLOOD TSH-1.1
[**2127-3-5**] 02:46AM BLOOD AMA-NEGATIVE
[**2127-3-5**] 02:46AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2127-3-11**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- Negative
for Heparin PF4 Antibody Test by [**Doctor First Name **]
MICRO:
[**2127-3-4**] 9:59 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2127-3-8**]**
GRAM STAIN (Final [**2127-3-4**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2127-3-8**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
Sensitivity testing confirmed by Sensititre.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
ERYTHROMYCIN AND OXACILLIN Sensitivity testing
confirmed by
Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>16 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2127-3-6**] Blood Culture, Routine (Final [**2127-3-12**]): NO GROWTH.
[**2127-3-6**] Blood Culture, Routine (Final [**2127-3-12**]): NO GROWTH.
[**2127-3-6**] 7:59 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2127-3-8**]**
GRAM STAIN (Final [**2127-3-6**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2127-3-8**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
[**2127-3-9**] 12:05 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2127-3-11**]**
GRAM STAIN (Final [**2127-3-9**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2127-3-11**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
[**2127-3-9**] Blood Culture, Routine (Final [**2127-3-15**]): NO GROWTH.
[**2127-3-9**] Blood Culture, Routine (Final [**2127-3-15**]): NO GROWTH.
[**2127-3-9**] URINE CULTURE (Final [**2127-3-10**]): NO GROWTH.
STUDIES:
[**2127-3-4**] CXR: Global right lung consolidation, probable
pneumonia, conceivably hemorrhage. Volume loss suggests some
bronchial compromise. CT recommended when feasible. ET tube
terminates 3 cm above carina appropriately.
[**2127-3-4**] CT HEAD: 1. No evidence of acute intracranial
abnormalities. 2. Extensive right scalp hematoma and right
facial subcutaneous edema.
[**2127-3-4**] ABD U/S: 1. Cirrhotic liver with reversal of flow within
the main and left portal veins. The right portal vein was not
assessed on this portable exam, which was also slightly limited.
2. Splenomegaly with trace ascites. 3. Gallbladder sludge with
mild gallbladder wall edema and pericholecystic fluid, likely
due to underlying liver disease.
[**2127-3-12**] TTE: Normal biventricular cavity sizes with preserved
regional and excellent/hyperdynamic biventricular systolic
function. Mild pulmonary artery systolic hypertension.
[**2127-3-14**] CXR: A right-sided PICC line tip is again seen at the
brachiocephalic/SVC junction. Diffuse opacity within the right
hemithorax
continues to worsen with decreased aeration of the right lung
base.
Multifocal opacities on the left are unchanged. There is no
pneumothorax.
Discharge Labs:
WBC=4.4
Hct=26.5
PLT=106
INR=1.7
K=4.1
Na=132
Cr=0.7
Phos=2.6
Tbili=1.7
AST=91
Rest of labs wnl
Brief Hospital Course:
42 F w/ h/o HCV cirrhosis found down in pool of bloody emesis w/
empty methadone bottle w/ sepsis and lactic acidosis [**2-19**]
aspiration PNA from decreased alertness.
.
#. RESPIRATORY FAILURE- Patient's respiratory failure was
attributed to aspiration pneumonia/pneumonitis in the setting of
altered mental status and methadone overdose (though of note did
not awaken with narcan). She was intubated on admission to the
MICU on AC ventilation. She was started on vanc/unasyn for
aspiration pneumonia coverage and sputum culture was sent.
Initial sputum culture grew MRSA. Patient continued on
antibiotic treatment but mental status, significant secretions,
and volume overload precluded weaning from vent. She was started
on diuresis with lasix IV (LOS balance was over 10 liters
positive at one point), requiring a drip for effective removal
of volume. Repeat sputum cultures were sent when patient spiked
temperature and had worsened CXR. Antibiotics were broadened to
vancomycin and zosyn, and when sputum grew out pseudomonas cipro
was added for double coverage. Patient was called out to the
floor with a plan for an 8 day course of antibiotics from day of
positive pseudomonal culture for VAP. Patient was successfully
extubated on [**2127-3-13**] and called out to the floor on [**3-15**] for
further management. She completed her course of antibiotics on
[**3-18**] and PICC line was discontinued. She was briefly given IV
acetazolamide to attempt to correct her alkalosis with minimal
improvement. Her oxygen requirement at time of discharge was 3L
NC and 70% face tent or 5L NC alone at times, with SpO2 around
93%. Persistent O2 requirement is likely mostly due to post-ARDS
syndrome and may take time to recover. However, she does not
appear significantly volume overloaded and she was discharged on
a diuretic regimen of furosemide 40mg PO daily and
spironolactone 50mg daily for a goal of net even. This may need
to be adjusted at the facility.
.
# Hypokalemia: Pt was persistently hypokalemic at time of
transfer out of the MICU. She was continually repleted and then
placed on standing 40mEq daily. She was also started on
spironolactone 50mg daily. She should have K checked relatively
frequently after discharge until level normalizes and she no
longer requires repletion. Standing KCl may need to be reduced
as well should she become hypperkalemic.
.
# RUQ Pain: the patient reported RUQ pain that started approx 2
months prior to admission. This was well controlled during
admission.RUQ ultrasound showed Gallbladder sludge with mild
gallbladder wall edema and pericholecystic
fluid, likely due to underlying liver disease. However, she
would benefit from further workup for this including ruling out
malignancy and gallstone disease.
.
# Hyponatremia: Pt [**Name (NI) **] was 138 throughout most of admission but
trended down to 132 at time of discharge. THis was attributed to
diuresis, incl. with acetazolamide. She should have sodium level
checked on Friday, [**3-21**] along with potassium and phosphate.
.
#. SHOCK- Patient presented with shock which was attributed to
distributive (septic) from RLL PNA/pneumonitis. Lactate was 6.7
on admission. She was started on levophed in the ED and this was
continued with NS boluses as well. Antibiotics, initially
vanc/zosyn, then vanc/unasyn were continued. She was gradually
weaned off levophed. Blood cultures were negative.
.
#. [**Name (NI) 32707**] Pt reportedly found down in pool of black bloody emesis
and had + NGT lavage. Etiologies could include gastritis, PUD,
AVMs. Patient had RUQ U/S with dopplers which showed cirrhotic
liver with reversal of flow within the main and left portal
veins. Patient has a history of portal hypertensive gastropathy.
Her hematocrits remained stable and she did not require any
blood transfusions in the MICU. She was continued on an IV PPI
until tolerating POs and then transitioned to once a day PO PPI,
which she should remain on per hepatology recs. She will benefit
from an EGD as an outpatient to assess for varices given her
known liver disease. [**Hospital1 18**] Hepatology will attempt to contact pt
with appointment time. Hct was stable at 26.4 at time of
discharge.
.
#. Altered mental status- Unclear etiology- believed to be
secondary to methadone overdose, lactic acidosis, and overall
septic picture. She was gradually weaned off of her sedation and
required zyprexa which was transitioned to seroquel to manage
her agitation. She was seen by psychiatry around the time of her
extubation, who felt that her overdose was not a suicide attempt
and thus she did not require a 1:1 sitter. They recommended
tapering her clonazepam given her history of dependence and
detox 1 year prior- she was on 0.5 mg qHS (to be continued for 2
days and then stopped) when she was called out to the floor.
Benzos were stopped prior to discharge and quetiapine should
continue to be weaned if possible until no longer taking
(currently on 25mg QHS). Psychiatry continued to believe she was
not a threat to herself or others.
.
#. Thrombocytopenia- Patient's platelets dropped during
admission. HIT antibody was sent and negative. Thrombocytopenia
was attributed to liver disease. No active bleeding.
.
#. Liver disease: The patient has known HepC. This is likely
contributing to her elevated INR, low PLT count, and peripheral
edema. She will be followed by hepatology post-discharge.
.
.
# Outstanding issues:
-monitor K closely and adjust standing KCl and spironolactone
prn
-monitor Na closely until normalizes
-adjust furosemide and spironolactone for goal of net even
-wean oxygen requirement as tolerated
-wean quetiapine to off if possible
-stop sc heparin once ambulating
-aggressive PT
-f/u with hepatology as outpt for EGD to r/o varices
-workup RUQ pain x 2 months, including r/o malignancy
-pt will need PCP at time of discharge from facility-may call
[**Telephone/Fax (1) 250**]
Medications on Admission:
None
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for Rash.
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
1. Respiratory Failure
2. Aspiration Pneumonia
3. Septic Shock
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after you were found down at
home. You were intubated and in shock. You were started on IV
antibiotics and given a large amount of IV fluids. You also had
evidence of an upper gastrointestinal bleed. Your breathing
function improved and you were extubated. You completed a course
of antibiotics. You also had issues with your electrolytes which
need to be monitored closely for now. Psychiatry also evaluated
you and felt that you were not a threat to yourself or others.
You will also need your blood counts checked and your diuretics
adjusted as needed.
.
Some of your medications were changed during this admission:
START spironolactone
START furosemide
START pantoprazole
START docusate
START senna as needed
START polyethylene glycol as needed
START heparin
START folic acid
START multivitamin
START quetiapine
START thiamine
.
Some of these medications may be removed prior to your discharge
from the facility you are being transferred to.
Followup Instructions:
If you don't have a primary care physician, [**Name10 (NameIs) **] should call
[**Telephone/Fax (1) 250**] to set up an appointment for a new one.
.
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/LIVER CENTER
Address: [**Doctor First Name **] STE 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
*Someone from this department will contact you to schedule an
appointment. You should see follow up with a doctor within 2
weeks.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.97",
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icd9pcs
|
[
[
[]
]
] |
16213, 16287
|
9102, 15007
|
328, 340
|
16394, 16394
|
3351, 3351
|
17574, 18176
|
2355, 2483
|
15062, 16190
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16308, 16373
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15033, 15039
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16570, 17551
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8982, 9079
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|
2966, 3332
|
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|
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|
3367, 4447
|
2512, 2952
|
16409, 16546
|
4463, 8003
|
1882, 2011
|
2027, 2339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,640
| 171,210
|
13800
|
Discharge summary
|
report
|
Admission Date: [**2137-7-9**] Discharge Date: [**2137-7-13**]
Date of Birth: [**2061-8-21**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy, resection terminal ileum and right
colon, exploration of aorta and mesenteric arteries
2. Abdominal aortogram, celiac stent, superior mesenteric artery
stent.
3. Second-look abdominal reexploration and resection of 188 cm
of nonviable small bowel.
History of Present Illness:
The patient is a 75 year old woman who presented on transfer
from an outside hospital with diarrhea, epigastric pain and a
35-pound weight loss over three months. Colonoscopy at the
outside hospital showed sigmoid stricture, a question of
ischemic colitis vs diverticulosis, and terminal ileum through
RT colon with superficial ulcers and dusky color. A CTA/MRA
showed 50% celiac axis/SMA stenosis.
Past Medical History:
HTN, hyperlipidemia, CAD, MI, COPD, PUD, mitral valve dz
PSH: CABGX4, hysterectomy
Social History:
Quit smoking 25 years ago, no ETOH use
Family History:
Non-contributory
Physical Exam:
T 97.2 HR 92 BP 122/75 RR 18 SpO2 93% 2L NC
Obese female in mild distress from abdominal pain
RRR
CTA bilaterally, diminished breath sounds at bases
Abdomen soft, mild diffuse tenderness, no rebound, +BS
Extremeties warm, no rashes
Pulses: dopplerable DP/PT pulses bilaterally
Pertinent Results:
[**2137-7-9**] 05:05PM BLOOD WBC-30.1* RBC-4.93 Hgb-14.2 Hct-42.5
MCV-86 MCH-28.7 MCHC-33.3 RDW-15.6* Plt Ct-249
[**2137-7-9**] 05:05PM BLOOD Neuts-83* Bands-5 Lymphs-6* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2137-7-9**] 05:05PM BLOOD PT-19.6* PTT-32.8 INR(PT)-1.9*
[**2137-7-9**] 05:05PM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-144
K-4.0 Cl-111* HCO3-19* AnGap-18
[**2137-7-9**] 05:05PM BLOOD ALT-59* AST-76* LD(LDH)-391* AlkPhos-97
Amylase-95 TotBili-0.4
[**2137-7-9**] 05:05PM BLOOD Lipase-10
[**2137-7-10**] 11:53AM BLOOD CK-MB-16* MB Indx-3.6 cTropnT-0.16*
[**2137-7-9**] 05:05PM BLOOD Albumin-3.4 Calcium-9.1 Phos-4.0 Mg-1.0*
Brief Hospital Course:
The patient is an elderly female, transferred to the [**Hospital1 18**] on
[**2137-7-9**] with chronic mesenteric ischemia who had some worsening
bowel complaints and elevated white count. On evaluation in the
hospital, she started to have some diminished pain and had no
focal findings. She had diffuse mild tenderness but no rebound
and guarding. The decision was made to hydrate her, repeat a CT
scan and plan for semi-elective percutaneous mesenteric
revascularization and potential laparotomy. However, over the
course of the night, her pain acutely worsened. The patient was
seen to have a white blood count of 30,000, a diffusely tender
abdomen and a sterile lactate of 8. Therefore, the patient was
taken urgently to the operating room on [**2137-7-10**].
Intraoperatively, there was seen to be an ischemic appearing
liver and diffuse ischemia of the small bowel. The only area of
transmural infarction that was visualized was an approximately 4
cm segment of the terminal ileum. The SMA was explored and was
circumferentially calcified as was the whole aorta. An attempt
at a bypass was not realistic because we would have had to come
from the supraceliac aorta at best and are arteries are
incredibly calcified. Therefore, the decision was made to close
the patient's abdomen, resuscitate her and then take her to the
endo suite for an attempt at percutaneous revascularization. She
was stabilized in the recovery room initially for approximately
an hour and a half and then transferred to the endo suite. Upon
transfer, she required more pressors. The patient had a cardiac
arrest during the procedure and required CPR, and medications
and transcutaneous pacing. Eventually, she regained her own
rhythm and had a blood pressure. One celiac artery stent and
superior mesenteric artery stent were deployed. The patient was
returned to the ICU in critical condition. There, the patient
remained in critical condition being dependent on vasopressor
support and high levels of mechanical ventilatory support.
Because of the fact that the patient had failed to clear her
lactic acidosis, the decision was made to reexplore the abdomen
to determine the viability of her remaining intraperitoneal
contents the very next day. Upon reexploration, 188cm of small
bowel were found to be non-viable and were therefore resected.
The patient's abdomen was closed, and she was returned to the
ICU, where she remained in profound shock requiring multiple
pressors to maintain blood pressure. The patient developed renal
failure, hepatic failure and coagulopathy. CVVHD was instituted.
Following multiple meetings with family, the patient's grim
prognosis was made clear. After lengthy discussion, the
patient's family elected to make her comfort measures only on
[**7-12**] at 1:30am. She expired shortly after at 2:08am.
Medications on Admission:
Atenolol 25, Zoloft 50, Captopril 50 qam, 25 pm, Lasix 40 mg IV,
Zocor 80, Protonix, Levaquin 500, Flagyl 500 TID, Tylenol,
Morphine, Reglan, Ambien 5
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Mesenteric ischemia
PVD
CAD, s/p MI
Discharge Condition:
Deceased
|
[
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icd9cm
|
[
[
[]
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[
"00.41",
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"45.73",
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icd9pcs
|
[
[
[]
]
] |
5260, 5269
|
2212, 5031
|
328, 604
|
5363, 5374
|
1544, 2189
|
1210, 1228
|
5232, 5237
|
5290, 5342
|
5057, 5209
|
1243, 1525
|
274, 290
|
632, 1032
|
1054, 1138
|
1154, 1194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,963
| 176,069
|
2840
|
Discharge summary
|
report
|
Admission Date: [**2178-7-8**] Discharge Date: [**2178-7-17**]
Date of Birth: [**2109-7-19**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 F, of unclear handedness, hx of DM2, HTN, HLD, prior DVT,
CRF, and metastatic endometrial CA, s/p recent onset of
taxol/carboplatin chemo, received her second cycle of chemo [**7-2**]
and since then has been acting "disoriented" per her son with
whom she lives. He notes for example, that she is easily
distractable, will wander from one room to another while in the
middle of a task (e.g. making a [**Location (un) 6002**]), however, has been
able
to complete her ADL's including cooking and going for walks to
the market. This morning, he saw her last normal around 6:30 am
and had helped give her insulin shot. When he returned from work
around 5:30 pm, he found her sitting on the floor of their
living
room, very confused and seeming overall fatigued. He was able to
move her to the couch and took her FS, which was 145. He then
called EMS. He felt her speech was dysarthric, but felt that
there was no focal weakness, sensory changes, HA, VC, ataxia,
trouble understanding or expressing language, or any B/B
incontinence. Of note, she had been on coumadin for her DVT up
until [**2178-6-6**], and was then switched to lovenox [**1-12**] her chemo
regimen.
Past Medical History:
hyperlipidemia
hypothyroidism
hypertension
status post thrombophlebitis (DVT)
metsatatic endometrial cancer s/p recent onset of
taxol/carboplatin chemo
diabetes type II
Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy
IVC filter placement
CRF
Social History:
Negative for alcohol or tobacco use. The
patient lives with her son, who is her primary caretaker.
Family History:
HTN
Physical Exam:
98.1F 112 110/67 16 100%RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple
CV: irreg irreg, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e; equal radial and pedal pulses B/L.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place given mult choices, but not
date. Inattentive, cannot say DOW forewards or backwards.
Speech is fluent with normal comprehension but poor repetition;
poor naming (calls fingers "hand", states "thumb" when asked to
name pointer finger. (+) dysarthria (seeming more gutteral).
Never learned how to read or write. (+) right left confusion.
(+) Left neglect (thinks her L hand is the examiner's hand)
Cranial Nerves:
Pupils equally round and reactive to light, 5 to 4 mm
bilaterally. Visual fields seem to show a L VF deficit (she has
poor BTT coming from the left). Extraocular movements intact
bilaterally, no nystagmus (though very difficult to get her to
voluntarily look left, eyes able to move left on VOR having her
fix on my nose and turning head side to side) Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Not completely cooperative with full strength testing, but
within
this context, appears to have full strength in the UE and in the
LE at the IP, Ham and Quad, with the exception of perhaps 5-/5
in
the Left Ham (though could be [**1-12**] inattention. Did not cooperate
with DF, PF, TE, TF testing)
Sensation: Seems to indicate a decrease in [**Last Name (un) 36**] to LT and PP in
the LUE and LLE, without a clear level. Otherwise intact to
light
touch, pinprick, and proprioception throughout. (+) extinction
to
DSS on the L.
Reflexes:
+2 and symmetric throughout except at patellae which were 0
(though again, not relaxing enough for appropriate testing)
Toes downgoing bilaterally
Coordination: Able to do finger to nose x 1 without clear ataxia
or dysmetria. Could not cooperate with further coord testing.
Gait: Narrow based, but very small steps, almost shuffling. Son
states this is quite different from baseline.
Romberg: Negative
Pertinent Results:
[**2178-7-17**] 02:22AM BLOOD WBC-10.2 RBC-1.75*# Hgb-5.5*# Hct-18.3*
MCV-105*# MCH-31.3 MCHC-29.9*# RDW-18.6* Plt Ct-8*#
[**2178-7-16**] 01:30AM BLOOD WBC-17.2*# RBC-2.48* Hgb-7.9* Hct-23.0*
MCV-93 MCH-32.1* MCHC-34.6 RDW-17.3* Plt Ct-23*#
[**2178-7-7**] 05:54PM BLOOD WBC-5.3 RBC-3.74* Hgb-12.4 Hct-36.3
MCV-97 MCH-33.1* MCHC-34.1 RDW-14.1 Plt Ct-80*
[**2178-7-16**] 01:30AM BLOOD PT-16.5* PTT-44.9* INR(PT)-1.5*
[**2178-7-11**] 02:43AM BLOOD Fibrino-417*
[**2178-7-17**] 02:22AM BLOOD Glucose-128* UreaN-56* Creat-4.5* Na-144
K-7.0* Cl-113* HCO3-5* AnGap-33*
[**2178-7-16**] 01:30AM BLOOD Glucose-74 UreaN-48* Creat-3.8* Na-145
K-4.5 Cl-114* HCO3-12* AnGap-24*
[**2178-7-7**] 05:54PM BLOOD Glucose-95 UreaN-24* Creat-1.8* Na-139
K-5.2* Cl-102 HCO3-25 AnGap-17
[**2178-7-16**] 01:30AM BLOOD CK(CPK)-1012*
[**2178-7-13**] 06:16PM BLOOD ALT-71* AST-99* LD(LDH)-413* AlkPhos-35*
TotBili-1.1
[**2178-7-7**] 05:54PM BLOOD ALT-56* AST-63* CK(CPK)-329* AlkPhos-74
TotBili-0.9
[**2178-7-16**] 01:30AM BLOOD CK-MB-21* MB Indx-2.1 cTropnT-0.52*
[**2178-7-15**] 09:02PM BLOOD CK-MB-22* MB Indx-2.4 cTropnT-0.52*
[**2178-7-7**] 05:54PM BLOOD CK-MB-6 cTropnT-0.34*
[**2178-7-17**] 02:22AM BLOOD Calcium-7.9* Phos-11.3*# Mg-2.8*
[**2178-7-8**] 04:00AM BLOOD %HbA1c-6.2*
[**2178-7-8**] 06:10AM BLOOD Triglyc-101 HDL-66 CHOL/HD-2.8
LDLcalc-102
[**2178-7-7**] 05:54PM BLOOD TSH-0.92
[**2178-7-7**] 05:54PM BLOOD Free T4-2.1*
[**2178-7-7**] 05:54PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2178-7-17**] 02:33AM BLOOD Type-ART pO2-73* pCO2-32* pH-6.85*
calTCO2-6* Base XS--30
[**2178-7-16**] 11:52PM BLOOD Type-ART pO2-90 pCO2-42 pH-6.76*
calTCO2-7* Base XS--32
[**2178-7-12**] 08:03PM BLOOD Type-ART pO2-105 pCO2-24* pH-7.37
calTCO2-14* Base XS--9
[**2178-7-17**] 02:33AM BLOOD Lactate-16.2*
[**2178-7-16**] 11:52PM BLOOD Lactate-13.6* K-6.4*
[**2178-7-7**] 05:49PM BLOOD Glucose-90 Lactate-2.1* K-7.6*
[**2178-7-7**] 06:13PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2178-7-7**] 06:13PM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2178-7-7**] CT head;
IMPRESSION: New rounded areas of hypodensity within the left
temporooccipital
and parietal lobes and left cerebellum concerning for metastatic
disease in
patient with history of endometrial cancer. An MRI with and
without contrast
is recommended for further evaluation.
[**2178-7-9**] MRI brain:
FINDINGS: There are multifocal areas of high T2/FLAIR signal
intensity within the supra and infratentorial compartments, with
large areas of abnormality involving the posterior right
temporal and medial left temporal lobes. Additional foci are
seen in the occipital lobes, deep white matter, and scattered
throughout the cerebellum. The larger of the lesions demonstrate
high signal on DWI with corresponding low signal on ADC,
compatible with infarcts. The smaller lesions are too small to
characterize on the ADC maps.
There is no evidence of intracranial hemorrhage or shift of
normally midline structures. No discrete mass is identified,
though assessment is limited as there were no post- contrast
imaging. The ventricles and sulci are mildly prominent, likely
affecting age- related atrophy. Visualized paranasal sinuses and
mastoid air cells are normally aerated.
On MRA, the carotid and vertebral arteries appear within normal
limits without evidence of stenosis, occlusion, or aneurysm
formation.
IMPRESSION:
1. Multifocal infarcts within the supra and infratentorial
compartments,
including watershed regions. These findings most likely
represent embolic
infarcts, as the vasculature appears patent without stenosis or
occlusion.
2. Limited assessment for intracranial metastases as no
post-contrast images were obtained, as detailed.
[**7-10**] CT brain:
IMPRESSION:
1. New parenchymal hemorrhage of the medial left temporal lobe,
which may be hemorrhagic transformation in the region of the
infarct on MRI [**2178-7-9**] or may be due to trauma. Probable
parenchymal hemorrhage of the right
temporal lobe and left cerebellar hemisphere.
2. Multiple foci of supratentorial hemorrhage, some subarachnoid
in location, others may be parenchymal or subarachnoid
hemorrhage.
[**2178-7-11**] MRI brain;
IMPRESSION: Multiple evolving infarcts identified in the supra-
and
infratentorial regions with enhancement at the site of the
infarcts. Although
most of the areas of enhancing lesions are likely due to
infarcts, small
associated metastatic lesion would be difficult to evaluate . A
followup MRI can help to exclude associated tiny metastatic
lesions.
[**2178-7-12**] CT head;
IMPRESSION:
1. Multiple foci of ischemia/infarction demonstrate evolution,
with increase in size and more hypodense appearance.
2. Largest area of ischemia/infarction in the right
temporoparietal region
demonstrates an approximately 1 cm focus of hyperdensity
consistent with a
small focus of hemorrhage.
[**2178-7-13**] transthoracic echocardiogram;
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thicknesses and cavity
size are normal. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. There is mild
global left ventricular hypokinesis (LVEF = 40 %) (?related to
the tachycardia). Systolic function of apical segments is
relatively preserved (suggesting a non-ischemic cardiomyopathy).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
moderate [2+] tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild global left
ventricular hypokinesis. Mild pulmonary artery systolic
hypertension. Moderate mitral regurgitation. Moderate tricuspid
regurgitation.
Compared with the prior study (images reviewed) of [**2178-7-8**],
the heart rate is much higher and the global LVEF is now mildly
depressed. The severity of mitral regurgitation and tricuspid
regurgitation have increased.
Brief Hospital Course:
Ms. [**Known lastname 13834**] is a 68 yo F, of unclear handedness, hx of DM2,
HTN, HLD, prior DVT, CRF, and metastatic endometrial CA, s/p
recent onset of taxol/carboplatin chemo, received her second
cycle of chemo [**7-2**] and since then has been acting "disoriented"
per her son, who today was found on the ground in with more
substantial MS changes and dysarthria. Her NCHCT shows a L-PCA
territory hypodensity as well as a L cerebellar hypodensity most
c/w a subacute stroke. She also was found to have
acute-on-chronic renal failure, mild hyperkalemia, and a
thrombocytopenia at the time of admission. She was evaluated by
cardiology given her troponin of 0.3 in the setting of
creatinine of 1.8. It was thought she did not have any evidence
of acute coronary syndrome and the troponin leak may have been
due to imbalance of the autonomic nervous system with excessive
sympathetic activity and catecholamine release secondary to her
stroke vs. demand ischemia, and possibly also contributed from
her renal failure. She was transferred to the medicine service
given her multiple comorbidities and followed by the stroke
consult service. For her likely embolic strokes, she was
continued on lovenox and was deemed not to be an aspirin
candidate due to her thrombocytopenia (platelet count in
30s-40s). On [**7-10**], the patient was found on the floor of her
hospital room at approximately 4:30 PM after an unwitnessed
fall. A repeat CT head on [**7-10**] revealed new parenchymal
hemorrhage of the medial right temporal lobe. This may be
hemorrhagic transformation in the region of infarct on MRI
[**2178-7-9**] or due to trauma. Multiple foci of possible subarachnoid
or intraparenchymal hemorrhage were seen on the [**7-10**] Head CT.
However, subsequent MRI brain on [**7-12**] did not corroborate these
areas of possible subarachnoid or intraparenchymal bleed.
The patient could not provide any history but had no complaints
when examined and denied headache or neck pain. She was
transferred to the neuro ICU, lovenox was discontinued, and she
was transfused platelets, fresh frozen plasma, and started on
keppra for seizure prophylaxis. She was evaluated by
neurosurgery who did not recommend any surgical intervention.
The patient continued to be quite somnolent during the remainder
of her hospital course, and became more lethargic over the next
24 hours, no longer following commands. She became hypotensive
(SBP down to 60s), requiring three pressors, and intubated. On
[**7-13**] her examination worsened. She was no longer withdrawing her
right arm or leg to noxious stimuli and remained on three
pressors. Her lactate was rising, renal failure worsening with
very little urine output, and anemia and thrombocytopenia were
worsening as well. On [**7-17**], the patient was no longer breathing
over the ventilator and her pupils were fixed and dilated. Her
MAP dropped to 40-50, and she was given IVF 250 cc boluses x2.
There was question of SVT vs. atrial fibrillation on telemetry
and EKG, and she was started on diltiazem gtt for 1 hour. This
was turned off because her blood pressure had then dropped. The
patient was turned at 9:30-10, and bradyed to the 40s and
dropped her pressure to the 70s. She was given 0.5 Atropine, but
never lost her pulse. She did not receive chest compressions.
She was tachycardic after receiving Atropine. She was no longer
overbreathing the vent. Her pH was 6.76, and bicarb was started.
Her exam showed blistering of her skin which was very edematous,
black colored fingernails and extremities very cold to the
touch. Pupils are 7 mm and fixed,
nonreactive to light. Unable to elicit corneal reflexes. Unable
to elicit gag reflex. No spontaneous movement of her
extremities, she does not withdraw any extremity to noxious. It
was thought she had most likely herniated given that she has
lost her brainstem reflexes. She remained on ICU-level care
until her son could come in the following morning. She was
pronounced dead shortly thereafter.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 20 mg Tablet - take one Tablet by mouth
daily
ENOXAPARIN [LOVENOX] - 100 mg/mL Syringe - 1 injection
subcutaneously once daily
LEVOTHYROXINE - 50 mcg Tablet - 1 (One) Tablet(s) by mouth once
a
day
LISINOPRIL - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
three times daily for 3 days following chemotherapy
RISPERIDONE - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime
TRUE TRACK LANCETS - - use twice daily
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [TRUETRACK TEST] - Strip - use for
glucose testing twice a day
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30 PEN] - 100 unit/mL
(70-30) Insulin Pen - 22 u q am
Previously on warfarin at the below dose, but DC'd [**2178-6-6**] and
Lovenox started.
WARFARIN [JANTOVEN] - 2 mg Tablet - 3 (Three) Tablet(s) by mouth
2 days a week and two tablets by mouth 5 days a week.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
1. multiple strokes, likely embolic etiology
2. intraparenchymal and subarachnoid hemorrhage
3. acute on chronic renal failure
4. metastatic endometrial cancer
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
|
[
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"287.4",
"038.49",
"785.52",
"348.4",
"250.02",
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"427.89",
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"759.89",
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"342.00",
"351.8",
"410.71",
"197.0",
"348.30",
"284.1",
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"99.05",
"99.07",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15820, 15829
|
10810, 14826
|
345, 351
|
16032, 16049
|
4446, 10787
|
16113, 16131
|
1973, 1978
|
15791, 15797
|
15850, 16011
|
14852, 15768
|
16073, 16090
|
1993, 2300
|
284, 307
|
380, 1547
|
2837, 4427
|
2339, 2821
|
2324, 2324
|
1569, 1839
|
1855, 1957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,345
| 191,140
|
34072
|
Discharge summary
|
report
|
Admission Date: [**2153-6-7**] Discharge Date: [**2153-6-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Placement of pacemaker
History of Present Illness:
86 YO male presented to [**Hospital3 934**] ED in complete heart
block. He was at adult day care on the day of admission when
staff checked his vital signs around 12:00 noon and found him to
have a heart rate in the 30s. His daughter was called and picked
up the patient and took him to his PCP where [**Name Initial (PRE) **] 12 lead EKG
revealed him to be in complete heart block. He has had decreased
energy for several weeks and has been less active. Per his
daughter, he is pleasantly confused at baseline and was at his
baseline mental status on presentation to the ED and upon
transfer to [**Hospital1 18**]. He denies chest pain, SOB, nausea, vomiting,
diarrhea, syncope, lightheadeness. He does endorse mild
abdominal pain but denies any diarrhea or other [**Hospital1 **] symptoms.
.
At the [**Hospital **] Hospital ED, his VS were T 97.4, P 39, RR 16, BP
184/67, O2 sat 98% 02 on 3 L NC. He was transferred to [**Hospital1 18**] for
temporary transcutaneous pacemaker placement due to complete
heart block with wide ventricular escape at 35 bpm. A temporary
transcutaneous pacer was advanced to the RV apex via fluroscopic
guidance and position was confirmed with fluorscopy. V threshold
was set at 0.8 mA and V sensitivity threshold at >20 ms. [**First Name (Titles) **] [**Last Name (Titles) 78612**]s: VVI 70, V output 10 mA, V sensitivity 3 mV.
.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Dementia
4. CABG X4 vessels ([**2134**])
5. CVA ([**2137**])
6. CHF
7. Depression
8. Hypothyroidism
9. Barrett's esophabus
10.Eye surgery, unspecified
11. Elevated CRP, documented in PCP [**Name Initial (PRE) 626**] [**2148**] (3.8)
Social History:
SOCIAL HISTORY:
Social history is significant for the absence of current or
prior tobacco use. There is no history of alcohol abuse. Patient
is a retired pharmacist. Moved to [**Location (un) 86**] from [**State 108**] several
years ago to live with his daughter. Attends [**Name2 (NI) **] daycare.
.
Family History:
FAMILY HISTORY
There is no family history of premature coronary artery disease
or sudden death. Mother: [**Name (NI) 5895**] (deceased, COD: pneumonia).
FAther: unknown [**Last Name **] problem (deceased).
Physical Exam:
VS: T 97.6, BP 137/31, HR 37, RR 23, O2 98% on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no appreciable JVD.
CV: 2/6 SEM at RUSB and LUSB. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2153-6-7**] 08:01PM GLUCOSE-115* UREA N-26* CREAT-1.3* SODIUM-140
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2153-6-7**] 08:01PM estGFR-Using this
[**2153-6-7**] 08:01PM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.5
[**2153-6-7**] 08:01PM TSH-7.4*
[**2153-6-7**] 08:01PM WBC-6.2 RBC-3.32* HGB-10.6* HCT-31.0* MCV-93
MCH-31.8 MCHC-34.1 RDW-13.8
[**2153-6-7**] 08:01PM PLT COUNT-229
.
STUDY: CT of the head without contrast. [**2153-6-8**]
There is a large area of encephalomalacia involving the left
occipital lobe, vascular territory of the left posterior
cerebral artery, multiple areas of low attenuation in the
periventricular white matter, indicating chronic microvascular
ischemic disease, there is no evidence of acute hemorrhagic
changes or shifting of the normally medial structures. Punctate
dense atherosclerotic calcifications are visualized in the left
medial cerebral artery, carotid siphons, and vertebral body
basilar systems. Prominence of the sulci and ventricles is also
noted, likely age related and involutional in nature. Prominence
of the tip of the basilar artery is also noted, the possibility
of arteriosclerotic changes versus aneurysmatic formation are
considerations, CTA of the head is recommended if clinically
warranted. The orbits appear grossly normal, the paranasal
sinuses demonstrate normal pneumatization, as well as the
mastoid air cells.
IMPRESSION: Chronic ischemic changes are visualized on the left
occipital
lobe with associated encephalomalacia and asymmetry of the left
occipital
ventricular [**Doctor Last Name 534**]. Multiple areas of low attenuation are
demonstrated in the periventricular white matter, likely
consistent with chronic microvascular ischemic changes. There is
no evidence of acute hemorrhage or subdural hematoma. Dense
arteriosclerotic calcifications are demonstrated in the carotid
siphons, left medial cerebral artery, and vertebrobasilar system
as described above. Prominent tip of the basilar artery is
demonstrated, possibly related with arteriosclerotic changes, a
small aneurysm cannot be completely excluded, CTA or MRA are
recommended for further characterization of these findings.
These findings were communicated to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time
of this interpretation.
.
CTA HEAD W&W/O C & RECONS Study Date of [**2153-6-10**]
Prominence of the ventricles and sulci is related to age-related
parenchymal atrophy. Periventricular white matter
hypoattenuation is consistent with chronic small vessel ischemic
disease. There is again calcification of the middle cerebral
arteries, carotid siphons,
and vertebrobasilar arterial system. There is no hemorrhage,
edema, mass
effect, or shift of normally midline structures. There is ex
vacuo dilatation of the posterior [**Doctor Last Name 534**] of the left lateral
ventricle with surrounding encephalomalacia, consistent with
prior infarction.
CTA HEAD: There is prominence at the tip of the basilar artery,
which may
represent a patulous basilar artery or a small aneurysm. Poor
arterial
opacification and lack of processed imaging limits evaluation.
When processed images are become available, a separated addendum
will be provided.
IMPRESSION:
1. Prominence of tip of basilar artery may represent patulous
basilar artery versus small aneurysm. Poor arterial
opacification and lack of processed image limits evaluation, but
an addendum will be generated.
2. Calcifications of the intracranial vessels.
3. Age-related parenchymal atrophy.
4. Chronic small vessel ischemic disease.
5. Encephalomalacia of the left occipital lobe, likely from
prior infarction.
.
ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). No masses or
thrombi are seen in the left ventricle. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic and mitral regurgitation. Mildly dilated thoracic
aorta.
Brief Hospital Course:
#Rhythm-The patient was transferred to [**Hospital1 18**] for temporary
transcutaneous pacemaker placement due to complete heart block
with wide ventricular escape at 35 bpm. A temporary
transcutaneous pacer was advanced to the RV apex via fluroscopic
guidance and position was confirmed with fluorscopy. V threshold
was set at 0.8 mA and V sensitivity threshold at >20 ms. [**First Name (Titles) **] [**Last Name (Titles) 78612**]s: VVI 70, V output 10 mA, V sensitivity 3 mV. Pt
subsequently had a pacemaker placed without complication. He
did well and was monitored on telemetry x48 hours post
procedure. He was started on Metoprolol 12.5mg [**Hospital1 **] after the
pacemkaer was placed for his known CAD.
.
# Pump: Overall EF 45% from [**2147**] with global hypokinesis
suggesting systolic dysfunction. An echo was done which showed
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). He was
started on 40mg Lasix prior to discharge.
.
# CAD/Ischemia: Pt ruled out for an MI. He was continued on his
lipitor, plavix, ramipril per home dosing. He was started on
Metoprolol twice daily and aspirin.
.
#. Hypothyroidism- Initially there was concern that the patient
may be hypothryoid which could contribute to heart block however
TSH was wnl. Endocrine consulted at first but pt was on adequate
synthroid replacement. He remained on his home synthroid dose
and appt made for endocrine followup on discharge.
.
# [**Name (NI) 78126**] Pt has dementia at baseline per daughter.
.
# Basilar artery aneurysm/Left posterior infarct. Given mental
status changes, there was initial concern for an intracerebral
abnormality (given history of fall at home) and thus CT head was
done. It showed no hemorrhage, but there was concern for a
basilar artery aneurysm. Thus, a CTA Head was done which showed
prominence of the tip of a basilar artery which may represent
patulous basilar artery versus small aneurysm. Further followup
with the patient's PCP regarding this possible aneurysm is
recommended; however, no acute neurosurgical interventions were
deemed necessary. The patient was also noted to have a large
left posterior old infarct with associated encephalomalacia and
chronic SVID on this scan, likely related to ischemic dementia.
Medications on Admission:
1. Reminyl 8 mg PO BID
2. Zoloft 100 PO daily
3. Altace 10 mg PO daily
4. Lasix 20 mg PO daily
5. Lipitor 10 mg PO daily
6. Plavix 75 mg PO daily
7. Hydtrin 5 mg PO daily
8. Synthroid 175 mcg PO daily
9. Ranitidine 150 mg PO daily
10. KDur 20 mg PO dialy
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Galantamine 4 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Alzheimer's Disease.
8. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
Primary
1. Mobitz Type II heart block
.
Secondary
1. Hypertension
2. Hypercholesterolemia
3. Dementia
4. Coronary artery disease
5. Hypothyroidism
6. Congestive heart failure
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital for an irregular heart rhythm.
You had a temporary pacing wire placed and then had a pacemaker
placed to help control your heart rate.
.
There were changes made to your medications. You were started
on new medications, including Metoprolol 12.5mg twice daily.
You were also started on Lasix 40mg daily to help maintain your
fluid status.
.
You will need to follow up with device clinic. An appointment
was made for you. In addition you should be seen by
endocrinology as scheduled.
Followup Instructions:
Please followup with Dr. [**First Name (STitle) **], your PCP on [**7-3**] at 3:30 pm or
at least one week after patient leaves rehabilitation. Phone
[**Telephone/Fax (1) 22468**].
.
A followup appointment has been made with endocronologist,
Provider: [**Name10 (NameIs) 16244**] [**Last Name (NamePattern4) 16245**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2153-7-16**] 1:40
.
***Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2153-6-18**] 1:30
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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11352, 11417
|
7913, 10220
|
272, 297
|
11636, 11671
|
3420, 7890
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12238, 12742
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2324, 2532
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10246, 10503
|
11695, 12215
|
2547, 3401
|
221, 234
|
325, 1689
|
1711, 1989
|
2021, 2308
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,876
| 179,743
|
17234+17235
|
Discharge summary
|
report+report
|
Admission Date: [**2164-4-30**] Discharge Date: [**2164-5-13**]
Date of Birth: [**2116-1-22**] Sex: M
Service: CSU
ADMISSION DIAGNOSES:
1. Left lower extremity wound dehiscence.
2. Insulin dependent diabetes mellitus with neuropathy.
3. Hypertension.
4. Peripheral vascular disease.
5. Status post appendectomy.
6. Status post hernia repair.
7. Status post right trans-metatarsal amputation.
8. Status post right above knee popliteal to dorsalis pedis
bypass graft.
9. Status post left superficial femoral artery to dorsalis
pedis bypass graft.
10. Status post amputation fourth toe.
DISCHARGE DIAGNOSES:
1. Left lower extremity wound dehiscence.
2. Insulin dependent diabetes mellitus with neuropathy.
3. Hypertension.
4. Peripheral vascular disease.
5. Status post appendectomy.
6. Status post hernia repair.
7. Status post right trans-metatarsal amputation.
8. Status post right above knee popliteal to dorsalis pedis
bypass graft.
9. Status post left superficial femoral artery to dorsalis
pedis bypass graft.
10. Status post amputation fourth toe.
11. Myocardial infarction.
12. Acute renal insufficiency.
13. Blood loss anemia.
14. Status post coronary artery bypass grafting x 3.
15. Congestive heart failure.
16. Status post cardiac catheterization with stenting.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname 35098**] is a 48 year old
male with a history of diabetes and extensive peripheral
vascular disease, for which he has had multiple bypasses. He
presented on [**2164-4-30**] to the vascular surgery service
for evaluation and care of a wound dehiscence of his left
lower extremity, where he had previously undergone a left
superficial femoral artery to dorsalis pedis bypass graft.
It was noted on his initial presentation that he had an
episode of nausea and chest pain the day prior, which
prompted a workup with an EKG which showed new ST segment
depressions. The patient had his cardiac enzymes cycled, and
ruled in for a myocardial infarction. On his initial
examination, he was afebrile and otherwise hemodynamically
normal. He did not appear to be grossly ill. His heart was
regular without rub. His lungs were clear and his abdomen
was otherwise soft. His left dorsalis pedis pulse was 2
plus, and his posterior tibial was 1 plus. On the right, his
dorsalis pedis and posterior tibialis were both one plus. He
notably had a 3 cm dehiscence of the left distal incision
over the lateral aspect of his ankle, with some exposed
graft. There was no purulence noted at the time.
His initial white count was 15.1, with hematocrit of 24.9.
His BUN and creatinine were 19 and 1.6.
HOSPITAL COURSE: The patient was admitted and, as noted,
ruled in for a myocardial infarction. He was initially
managed medically for his myocardial infarction, with plans
for a cardiac catheterization, which was made even more
urgent by the patient's respiratory distress, which was early
congestive heart failure.
On [**2164-5-1**], he was taken to the cardiac
catheterization lab and was found to have a heavily calcified
left anterior descending, with 90 percent stenosis mid-
vessel, along with a diffusely diseased left circumflex with
a focal 90 percent stenosis and an RCA with a 90 percent
proximal stenosis. During his catheterization, he underwent
placement of a cipher stent across the RCA stenosis. It was
felt that he would need coronary artery bypass grafting in
the near future. The patient's operation was delayed
secondary to the fact that he remained significantly febrile,
with a rising white blood cell count without a clear source.
It was most likely felt to be his foot, with a soft tissue
infection, as there was no evidence of other pneumonia,
urinary tract infection, bacteremia or osteomyelitis. He was
treated with broad spectrum antibiotics, including linezolid
and Zosyn. His congestive heart failure was managed
medically with judicious use of fluids and aggressive
diuresis in the intensive care unit, along with tight
glycemic control of his diabetes following [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consultation.
The patient developed acute renal insufficiency, which was
felt possibly to be secondary to the intravenous dye that he
had received, with a maximum creatinine of 2.0. He did make
urine throughout this period. After the patient had remained
afebrile and his white count had normalized, he was taken for
coronary artery bypass grafting x 3 on [**2164-5-7**]. He
underwent a left internal mammary artery to left anterior
descending, saphenous vein graft to OM, to OM2. There was no
note of intraoperative complication. His cardiopulmonary
bypass time was 47 minutes, with a cross clamp time of 37
minutes. He was taken intubated to the cardiac surgery
recovery unit on Neo-Synephrine and an insulin drip.
He was extubated on postoperative day zero, but required re-
intubation secondary to respiratory distress. Fortunately,
he was able to re-extubate by the end of postoperative day
one. His general postoperative course was quite good. After
weaning from sedation and after weaning from sedation, the
patient was continued on a CIWA protocol for prior history of
alcohol use. His pain was otherwise well controlled with
narcotics. He remained hemodynamically stable in a sinus
rhythm on standard postoperative cardiac medications,
including aspirin, Plavix and metoprolol. Lisinopril was
added to his regimen, given his history of congestive heart
failure, for improved control of his pressure and some
afterload reduction. The patient's chest tubes were out by
postoperative day two. He did require several transfusions
for blood loss anemia, with a low hematocrit of 20, but there
was no obvious significant source of bleeding prompting this.
The patient's diet was advanced. He was eating well. His
blood sugars were controlled on an insulin drip while in the
cardiac surgery intensive care unit, followed by subcutaneous
doses of insulin after transfer to the floor. His overall
volume overload was treated with daily doses of [**Year (4 digits) 11573**] toward
the goal of reaching his preoperative weight. By the time of
discharge, he was about 1.5 kg above his preoperative weight.
By postoperative day five, the patient was doing quite well.
His pain was controlled on oral Percocet. He was satting in
the mid nineties on room air. He was hemodynamically normal
on 50 of Lopressor twice per day and 5 of lisinopril once a
day in a sinus rhythm. He was tolerating a regular diet,
with control of his blood sugars on a combination of Glargine
and Humalog and a regular insulin sliding scale. His renal
function had improved, with a return of his creatinine to
baseline at 0.8. He was making excellent urine. He
continued to receive mild diuresis with [**Year (4 digits) 11573**] 40 mg p.o.
twice per day. He was being anticoagulated with Coumadin,
daily dosing which ranged between 1-5 mg per day, with a goal
INR of approximately 2.0. He had completed a two week course
of linezolid and Zosyn for the soft tissue infection of his
left leg, and, as noted, was afebrile, with a normal white
count of 11.3 and hematocrit of 27.8. It was felt that as he
was doing well, he could be discharged to home in safe
condition. Therefore, he was discharged to home on the
following medications:
Aspirin 81 mg p.o. once daily,
Zantac 150 mg p.o. b.i.d.
Percocet 5/325 1-2 tablets every 4 hours as needed for pain.
Plavix 75 mg p.o. once daily.
Lipitor 10 mg p.o. once daily.
Coumadin 3 mg p.o. at bedtime, daily dosing until stabilized
regimen as per primary care physician.
[**Name Initial (NameIs) 11573**] 40 mg p.o. two times per day for seven days (goal
diuresis of approximately two kg.).
Lisinopril 5 mg p.o. once daily.
Lopressor 50 mg p.o. twice daily.
His insulin is to be glargine 40 units at bedtime, along with
regular insulin sliding scale.
The patient is to follow up with Dr. [**Last Name (STitle) 70**] in six weeks.
He is to see Dr. [**Last Name (STitle) **] of vascular surgery in approximately
one and a half weeks for reassessment of his left lower
extremity wound. The patient will follow up with Dr.
[**Last Name (STitle) 5543**] of cardiology in [**11-23**] days. He will call for an
appointment, and the patient says he will see his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35266**], within five to seven days for
management of his diabetes, and also for dosing of his
Coumadin. He has agreed to have his INR checked in 2 days.
The patient states that he has a prescription from his
primary care doctor to already have this done. The patient
has declined followup with the [**Last Name (un) **] diabetes center, and
states he will have his diabetes managed by his primary care
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2164-5-13**] 13:10:18
T: [**2164-5-13**] 13:50:53
Job#: [**Job Number 48302**]
Admission Date: [**2164-4-30**] Discharge Date: [**2164-5-13**]
Date of Birth: [**2116-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Vancomycin
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
? wound infection, shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization
blood transfusion
CABG
History of Present Illness:
48 diabetic male s/p left SFA to DP bypass graft with in-situ
SVG ([**4-9**] Vascular) & s/p L 4th toe debridement ([**4-10**] Podiatry)
Podiatry admitted with cheif concern of right dorsal dehiscence,
wound infection and exposed graft. Night before admission, he
developed shortness of breath as well as nausea. Came to ED for
evaluation of dehiscence but was found to have EKG changes with
new 2-[**Street Address(2) 2051**] depressions in V5-V6. His enzymes were positive
with CK peak 437, MB 13, and Troponin T of 2.3. Assessed to have
NSTEMI- His cath showed 3 VD with 90% lesions of LAD, LCX, RCA,
and occluded OM 2. Cardiac surgery decided to proceed to CABG.
Pt transferred to the floor from the CCU. Two days of low grade
fevers resulted in negative fever workup including CXR, Bl Cx,
UCx, XR feet, US c/w small pinpoint left foot superficial fluid
collection too small to drain. Cardiac surgery took patient to
the OR on HD
Mr. [**Known lastname 35098**] is a 48 Male s/p left SFA to DP bypass graft (exposed)
with in-situ SVG ([**4-9**]) & s/p L 4th toe debridement ([**4-10**]) by
Podiatry now with dehiscence, wound infection and exposed graft
on the left. He then developed shortness of breath as well as
nausea. He was found to have EKG changes with new 2-[**Street Address(2) 2051**]
depressions in V5-V6. His enzymes were positive for MI with CK
peak 437, MB 13, and Troponin T of 2.3. His cath showed 3 VD
with 90% lesions of LAD, LCX, RCA, adn occluded OM 2.
Past Medical History:
DMI, HTN, PVD, Appy, Hernia, R TMA, R AK [**Doctor Last Name **]-DP, normal p-MIBI
and normal EF
Social History:
3 ppd smoker
mechanic
lives in [**Hospital1 1474**] with a friend
drinks 6-8 [**Name2 (NI) 17963**] per day
Family History:
uncle died of MI in his 40's
Physical Exam:
T 97.9 HR 73 BP 111/57 RR 14m 98% on NRB
Gen: NAD lying in bed, NRB in place
HEENT: PERRLA EOMI, MMM O/P clear
Cor: RRR no M/R/G
Pulm: fair air movement bilaterally, scattered rales bilaterally
at bases
Abd: soft ND ND obese
Ext: bilateral lower extremities with 30 cm well healed surgical
incision on right and poorly healed surgical incision on left.
Toes absent on right foot and small toe absent on left. Left
upper extremity with 8 cm well healed incision on volar aspect
of upper arm.
Pertinent Results:
[**2164-4-30**] 05:30PM CK-MB-13* MB INDX-3.0 cTropnT-2.30*
[**2164-4-30**] 05:30PM CK(CPK)-437*
[**2164-4-30**] 05:30PM GLUCOSE-136* UREA N-19 CREAT-1.6* SODIUM-136
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13
[**2164-4-30**] 05:30PM WBC-15.1*# RBC-2.96* HGB-8.5* HCT-24.9*
MCV-84 MCH-28.7 MCHC-34.1 RDW-15.7*
CXR IMPRESSION:
1) Perihilar haziness and diffuse interstitial opacities, most
likely due to pulmonary edema from fluid overload. Drug reaction
and interstitial infection are considered less likely but should
also be considered in the appropriate clinical setting.
2) Associated small pleural effusions, right greater than left.
Echo [**4-4**]:
The left atrium is markedly dilated. [Intrinsic left ventricular
systolic
function may be more depressed given the severity of valvular
regurgitation.] Overall left ventricular systolic function is
moderately depressed. (Ejection Fraction: 30% to 35%) Resting
regional wall motion abnormalities include anteroseptal and
apical hypokinesis/akinesis and mid to distal inferolateral
hypokinesis/akinesis. Right ventricular chamber size is normal.
The aortic root is moderately dilated. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
The mitral regurgitation jet is eccentric. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
LENI [**5-4**]
IMPRESSION:
1. No evidence of lower extremity DVT.
2. Tiny fluid collection at the left dorsal foot.
Brief Hospital Course:
1. CAD: Mr. [**Known lastname 35098**] was found to have an NSTEMI on admission- he
had a cardiac catheterization which found that he had 3vd (see
report) and had an RCA stent placed. He was transferred to CCU
then to [**Hospital Unit Name 196**] service awaiting CABG. He was continued on Plavix,
ASA, [**Last Name (un) **], Spironolactone.
.
2. CHF: Echo [**5-2**] demonstrated TR, severe MR, LVEF 30-35%.
Subsequent CXRs demonstrated worsening CHF which resolved with
diuresis. Continued on spironolactone, [**Last Name (un) **].
.
3. Fever: Patient developed a fever on HD 3, Max 102 [**5-2**]
afternoon then remained with low grade fevers 99-100 HD [**5-15**].
Blood cultures and Urine cultures negative, CXR without
infiltrate, no signs of osteo on XR, Vascular surgery feels
their wound is appropriate and uninfected, ID consulted, US of
left foot demonstrated tiny pinpoint fluid collection too small
to be drained. CT surgery willing to surgery when afebrile x
24hrs.
.
4. SFA Dehiscence: L dorsal foot superficial dehiscence with
graft exposure. Vasc surgery followed in house. Wet-dry dsg
changes daily
.
5. DM: He was followed by [**Last Name (un) **] in house and was maintained on
a tight insulin sliding scale with glargine recomended and
implemented with adjustments. Pt will need tight followup with
dr [**Last Name (STitle) 14116**] at [**Last Name (un) 387**] on discharge.
.
6. ARF: Baseline creatinine 0.9-1.0, on admission 1.6, max 2.0
s/p catheterization. Unsure etiology, but likely with contrast
nephropathy compoundation- trended down nicely. [**Last Name (un) **] restarted
HD3.
Medications on Admission:
Atenolol 75'[**Hospital1 **], Amlodipine 5', Coumadin [**6-15**]', Lipitor 10', ASA
325', Diovan 160'
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 weeks.
Disp:*42 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): have your INR checked by your primary doctor in 2 days.
Disp:*100 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime: check your blood sugar 4x/day.
Disp:*50 mL* Refills:*0*
11. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: please refoer to your sliding
scale.
Disp:*200 mL* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
vna of [**Location (un) 5450**] & Southern [**Location (un) 3844**]
Discharge Diagnosis:
-coronary artery disease (3 vessel disease) s/p RCA stent, s/p
CABG
-diabetes
-Left foot (s/p SFA-DP) bypass graft wound dehiscence and
?infection
-acute renal insufficiency (resolving)
-CHF
-HTN
Discharge Condition:
Good
Good
Discharge Instructions:
-use crutches to walk at all times until seen by your vascular
surgeon
-take all medications as prescribed, be especially vigilant with
your insulin and your antibiotics
-call your vascular surgeon with increasing drainage from your
wound, red streaking up your leg, or any other signs of
infection
-return to the ED or call your cardiogist if you have one, or Dr
[**Last Name (STitle) **] (your cardiologist here), for any chest pain,
worsening breathing or any other concerns.
-call Dr.[**Doctor Last Name **] office if you have worsening redness over
your chest incision, or increasing drainage from your chest
incision
-take 3mg of coumadin tonight. You goal INR = 2.0
Followup Instructions:
Followup with Dr [**Last Name (STitle) **] of vascular surgery in 10 days after
discharge to have him evaluate your left foot wound call for an
appointment [**Telephone/Fax (1) 1721**]
-Call Dr.[**Name (NI) 27686**] office and set up a follow up appointment
for 6 weeks after the date of your surgery
-Follow up with Dr [**Last Name (STitle) 14116**] at [**Telephone/Fax (1) 48303**] within one week to
assess your diabetes
-Call Dr.[**Name (NI) 48304**] office (Cardiology) and set up an
appointment to see him in [**11-23**] days.
-You should see your primary care doctor (Dr. [**Last Name (STitle) 35266**] next week
for general follow up.
Completed by:[**2164-7-27**]
|
[
"584.9",
"285.1",
"518.82",
"V49.73",
"410.71",
"428.0",
"250.61",
"305.00",
"682.6",
"305.1",
"357.2",
"998.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.72",
"96.04",
"99.04",
"96.71",
"36.07",
"39.61",
"36.15",
"99.07",
"36.12",
"37.23",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
16798, 16896
|
13585, 15198
|
9465, 9513
|
17136, 17147
|
11839, 13562
|
17869, 18556
|
11283, 11313
|
639, 2694
|
15351, 16775
|
16917, 17115
|
15224, 15328
|
2712, 9370
|
17171, 17846
|
11328, 11820
|
157, 618
|
9387, 9427
|
9541, 11022
|
11044, 11142
|
11158, 11267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,355
| 101,387
|
8303
|
Discharge summary
|
report
|
Admission Date: [**2160-11-3**] Discharge Date: [**2160-11-11**]
Date of Birth: [**2133-5-22**] Sex: F
Service: MED
Allergies:
Cephalosporins / Penicillins / Compazine
Attending:[**Known firstname 759**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
(ACOVE transfer note from [**Hospital Unit Name 153**])
The pt is a 27 y.o. female with interstitial lung disease status
post open lung biopsy on [**2160-10-8**], on chronic TPN for GI
dysmotility, suprapubic catheter for bladder atony who presented
to the ED with a two-day history of fevers to 101 F. She also
complained of chills, increased abdominal pain, nausea without
vomiting, bladder spasm, and mild headache. In ER her T was
101.4, HR 112, BP 95/69, RR 24 and she was 95% on 2L. Labs were
notable for a lactate of 2.4, alkpho of 161 aa WBC of 3.6 with
N89. Patient was empirically started on Vanc, Flagyl,
Levofloxacin, Linezolid for urosepsis vs. line sepsis. An
abdominal CT demonstrated a non-loculated pelvic fluid
collection for which surgery was following. One set of blood
cultures grew coag negative staphylococcus, and antibiotics were
transitioned to Vancomycin. The patient's blood pressure
responded to fluids and antibiotics and her temperature
normalized.
Of note the patient came with a history of vasculitis documented
by report from her PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16004**] on colectomy specimen
many years ago. Dr. [**Last Name (STitle) 16004**] reports the initial pathology was
done at [**Hospital6 4620**] and then reviewed a second
time at [**Hospital 4415**].
Dr. [**Last Name (STitle) **] referred her for a lung biopsy because patient she
had had
a previous lung biopsy which was "concerning for a diffuse
microthrombotic process without much in the way of inflammatory
infiltrates" as well as four months of progressive pulmonary
deterioration for which a course of IV salumedrol was tried.
Biopsy performed [**10-8**] showed no vasculitis/no amyloid.
On transfer to medical floor patient reported feeling weak, with
no change in her baseline shortness of breath, no diarrhea, no
fever or chills, no chest pain. She reported not ambulating at
baseline secondary to contractures in her legs. She reported
bloating in her stomach with some nausea but no emesis. She
denied photobia, cough, chills, neck stiffness, jaundice.
Past Medical History:
1. Neuropathic vasculitis. See note from Dr. [**Last Name (STitle) 6426**] of
Rheumatology on [**2155-11-17**] in OMR for complete details.
Diagnosed at the age of 13. The exact nature of the
vasculitis has not been completely characterized. Has been
on brief courses of steroids in the past. Status post
multiple organ biopsies including muscle, skin, liver, and
bowel demonstrating perivasculitis.
2. Gastrointestinal dysmotility syndrome diagnosed in [**2144**],
status post subtotal colectomy in [**2147**] with result in short
gut syndrome, on total parenteral nutrition via central line
since [**2148**].
3. Multiple central line infections including Staphylococcus
epidermidis, [**Female First Name (un) 564**], and Klebsiella.
4. Right internal jugular central line thrombosis in [**5-/2159**],
status post TPA therapy.
5. Interstitial pattern on chest x-ray, etiology unclear,
status post VATS. Biopsy showed organizing and organized
arterial thrombi with recanalization, patchy eosinophilic
inflammatory infiltrate extending into the pulmonary
arteries, patchy pulmonary scarring, and no evidence of
vasculitis. No exact diagnosis could be made. Pulmonary
function tests [**2159-5-14**] suggests a restrictive defect, no
lung volume is recorded.
6. Status post cholecystectomy in [**2149**].
7. Question of [**Doctor Last Name **] optic atrophy.
8. Anemia of chronic disease status post multiple blood
transfusions.
9. Reflex sympathetic dystrophy with chronic pain.
10. Bladder atony status post suprapubic catheter placement
in [**2150**].
11. History of gastroesophageal reflux disease.
12. Status post dental extraction.
13. Status post left salpingo-oophorectomy.
14. History of Vancomycin-resistant Enterococcus in urine.
15. Status post G-J tube placement in the past.
16. Status post multiple vascular stents right IJ, left
brachiocephalic, left iliac veins.
17. Eosinophilic pneumonia- the possibility of chemical irritant
exposure through intravenous injection was raised on her last
admission.
Social History:
Lives at home with mother and father, receives 24hour nursing
2x/week.
Family History:
Noncontributory.
Physical Exam:
T 97.2 BP 109/74 Hr 84 R 19 98% on intermittent 1L NC
General: ill-appearing, pale young woman
HEENT: PERRL 9 mm->8 mm EOMI, dry, evidence of scarring from
central line placement
CV: RRR, no evidence of JVD, evidence of port-a-cath
Respiratory: poor inspirator effort, mild expiratory grunts, no
flank pain
ABD: w/evidence of G-J tube, no evidence of erythema/crusting
around site suprapubic tube no evidence of erythema/crusting
aroudn site, with BS, soft, miminimal tenderness to paplpation
diffusely, no guarding, no rebound
EXT: pulses intact in UE,LE, 1+edema LE, patient able to move
all extremities
CN: [**3-13**] intact, symmetric, AOX3, sleepy, conversent
Pertinent Results:
RUQ ([**11-3**]) IMPRESSION: The hepatic veins are patent. Portal
vein pulsatility suggests right hepatic failure.
[**2160-11-3**] chest CT
1. The liver is enlarged and heterogeneous. This could be due to
edema. The
hepatic veins are not opacified with intravenous contrast which
could be due
to technical reasons, however due to the congestive appearance
of the
parenchyma this is concerning for Budd- Chiari syndrome.
Recommend ultrasound
of the liver with doppler for better evaluate.
2. Diffuse edema of the soft tissues.
3. Small amount of free fluid in the abdomen. There is a
partially loculated
fluid collection in the left pelvis. However, the fact that the
walls are not
enhancing suggests this is probably not an abscess.
[**2160-11-3**] 06:52PM LACTATE-1.8
[**2160-11-3**] 06:40PM GLUCOSE-77 UREA N-23* CREAT-0.7 SODIUM-141
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
[**2160-11-3**] 06:40PM ALT(SGPT)-24 AST(SGOT)-34 ALK PHOS-141*
AMYLASE-40
[**2160-11-3**] 06:40PM LIPASE-69*
[**2160-11-3**] 06:40PM ALBUMIN-3.0* CALCIUM-7.5*
[**2160-11-3**] 06:40PM CORTISOL-12.0
[**2160-11-3**] 06:40PM WBC-3.1* RBC-3.08* HGB-7.3* HCT-24.4* MCV-79*
MCH-23.9* MCHC-30.1* RDW-18.1*
[**2160-11-3**] 06:40PM NEUTS-85.2* BANDS-0 LYMPHS-10.4* MONOS-3.0
EOS-1.1 BASOS-0.3
[**2160-11-3**] 06:40PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2160-11-3**] 06:40PM PLT SMR-VERY LOW PLT COUNT-59*
[**2160-11-3**] 06:40PM PT-16.7* PTT-51.4* INR(PT)-1.8
[**2160-11-3**] 06:40PM FIBRINOGE-392 D-DIMER-790*
echo: [**2160-2-4**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly
dilated. Right ventricular systolic function appears depressed.
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 estimated pulmonary artery
systolic pressure
cxray [**2160-11-3**]
IMPRESSION:
1. Stable interstitial pattern of opacity, in keeping with
known history of
vasculitis. Other inflammatory processes and mild interstitial
edema cannot
be excluded.
2. Lucency of the distal clavicle with possible distal
clavicular fracture.
Dedicated radiograph of the clavicle are suggested if clinically
warranted.
[**2160-8-27**]
PFTs
SPIROMETRY 1:38P Pre drug
Actual Pred %Pred
FVC 0.93 4.32 22
FEV1 0.92 3.43 27
MMF 1.04 3.81 27
FEV1/FVC 99 79 125
Impression: Unacceptable test quality precludes interpretation
of results.
Biopsy: [**2160-10-8**] biopsy:
Her final pathology is back and demonstrates extensive organized
arterial thrombi with focally associated foreign material.
There
is no evidence of vasculitis. Microbiology is all negative.
This is felt to be associated with her chronic TPN use.
Brief Hospital Course:
27 year old with history of neuropathic vasculitis, interstial
lung disease status post recent lung biopsy, subtotal colectomy
on chronic TPN, and G-J tube who presented to [**Hospital Unit Name 153**] on [**11-3**] with
fever and concern for line sepsis.
1. Fever - Pt was admitted to [**Hospital Unit Name 153**] on linezolid for coverage of
suspected line infection given her past history of VRE. She was
also started on levofloxacin and metronidazole for a possible
intra-abdominal infection with fluid collection seen on CT A/P.
One of two sets of blood cx drawn on admission grew coag-neg
staph. Levofloxacin, metronidazole, and linezolid were
discontinued, and vancomycin was started for treatment of likely
Staph epidermidis line sepsis. (Micro grew coag negative staph)
Interventional followed the patient and suggested to treat with
antibiotics through the line, rather then discontinue the line
because the patient has few access options. No pneumonia noted
on cxray. Liver function tests were notable for an elevated alk
phosphatase. She ultimately grew gram negative rods as well late
in the afternoon of [**2160-11-10**] and was placed on Levofloxacin.
Infectious disease was consulted to evaluate the patient on
[**2160-11-11**].
2. Anemia/Leukopenia - Patient with history of anemia 23-31.
History of leukopenia (1.9-4.0) In house, hematocrit dropped to
21 level from initial 27, thought secondary to fluid/possible
reaction to Linezolid. Patient hematocrit up to 22 on [**11-7**].
Patient was guiac negative on admission.
3. Partially loculated fluid collection in the left pelvis - Of
note patient with fluid collection noted on CT. Surgery has
been following patient and has no current intent to intervene.
Infectious disease called to comment. Would have evaluated
patient on [**2160-11-11**].
4. On [**2160-11-11**] at approximately 12:30 am, the nurse found the
patient unresponsive and stiff. A code was called and the
patient was pronounced dead. It is unclear what the cause of
death was as the patient did not appear septic and her vitals
until that time were stable. By report, she had been seen by
nursing less than an hour before she was found and had been
"fine." It did not appear that the PCA had been activated prior
to the patient's demise. The patient's father was [**Name (NI) 653**] as
the mother was out of the state. Both parents, once informed,
declined an autopsy.
Medications on Admission:
On transfer from [**Hospital Unit Name 153**]:
1. MED Heparin Flush Hickman (100 units/ml) 2 ml IV QD:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen QD and PRN. Inspect site every shift. [**11-3**]
@ 2308
2. MED Ondansetron 2 mg IV Q6H:PRN [**11-3**] @ 2308
3. MED Diphenhydramine HCl 100 mg IV Q3HR PRN
hold for excess sedation [**11-3**] @ 2308
4. MED Lorazepam 4 mg PO/IV Q4H:PRN
hold for sedation [**11-4**] @ 0817
5. MED Hydromorphone 4 mg IVPCA Lockout Interval: 6 minutes
Basal Rate: 4 mg(s)/hour 1-hr Max Limit: 28 mg(s)
per home dose [**11-4**] @ 1331
6. MED Enoxaparin Sodium 40 mg SC Q24H [**11-4**] @ 1436
7. MED Estraderm *NF* 0.1 mg/24 hr Transdermal twice per week
please place today [**2160-11-4**] and Friday [**2160-11-7**] and then all
following Tuesdays and Fridays [**11-4**] @ 1758
8. MED Vancomycin HCl 1000 mg IV Q12H [**11-5**] @ 1147
9. MED Calcium Gluconate 2 gm / 100 ml IV ONCE Duration: 1 Doses
[**11-6**] @ 1755
10. MED Insulin SC (per Insulin Flowsheet) Sliding Scale 10/07
@ [**2073**]
11. MED Potassium Chloride 40 mEq / 100 ml IV ONCE Duration: 1
Doses [**11-7**] @ 0903
12. IV IV access: Hickman [**11-3**] @
Discharge Medications:
Dilaudid 4 mg/hr basal rate with 4 mg per push with 10-min
lockout and max of 28 mg/hr
enoxaparin 30 mg/0.3 ml daily
furosemide 20 mg IV bid
diphenhydramine 100 mg IV q3h prn
metoclopramide 10 mg IV q12
ondansetron 10 mg IV five times daily prn
lorazepam q3 prn
pepcid 40 mg IV q12
Discharge Disposition:
Home
Discharge Diagnosis:
Line sepsis
Discharge Condition:
Deceased.
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83,433
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47983
|
Discharge summary
|
report
|
Admission Date: [**2125-9-12**] Discharge Date: [**2125-9-19**]
Date of Birth: [**2044-5-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
altered mental status, hypoxia
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram [**2125-9-18**]
History of Present Illness:
History of Present Illness: Mr. [**Known lastname **] is an 81 yo M with
rheumatic heart disease (c/b aortic stenosis s/p recent [**Known lastname 1291**]/MVR
on [**2125-7-3**]) and atrial fibrillation who presents from his
rehabilitation center with altered mental status.
.
The patient was recently admitted to the cardiothoracic service
from [**2125-7-2**] - [**2125-7-26**] for worsening shortness of breath thought
to be due to worsening AS, MR, and worsening heart failure (EF
40%). He was taken to the OR on [**7-3**] for aortic valve replacement
with a St. Jude's valve, aortic endarterectomy, and MVR with a
[**Company 1543**] mosaic tissue valve. His hospital course was
complicated by hypotension requiring pressor support and
eventual failure to extubate due to altered mental
status/encephalopathy and inability to handle secretions. He
received trach and PEG on [**2125-7-17**]. He also received 7 days of
Vancomycin and Cefepime for the secretions (presumably for
emperic treatment of VAP). Of note, he did have some delerium
noted at night -- seroquel was attempted but discontinued due to
somnolence.
He was tolerated trach collar, PM valve, and tube feeds prior to
discharge to [**Hospital6 1293**].
.
His daughter reports that at baseline, he has baseline dementia
but has some baseline cognitive function, including being alert,
interactive, and talkative. Of note, trach was also removed at
rehab. However, his mental status at rehab has been waxing and
[**Doctor Last Name 688**] during his rehab stay (documented in multiple
cardiothoracic NP[**MD Number(3) 29639**] as having confusion at rehab
occasionally requiring restraints and wandering), but noted by
his dtr to be worsening over the past week since he was
transferred to a new [**Hospital1 1501**]. He has had episodes of jerking
movements of his fingers or a 'kick' of the legs.
Independently, he also has episodes of lethargy, where he falls
"asleep" mid-sentence, is unresponsive to tactile or verbal
stimuli, then returns to his baseline but appears
drowsy/confused. These unresponsive episodes were occurring [**2-28**]
times a day, but were also increasing in frequency during the
week prior to admission. Haldol and Trazodone have been
attempted at rehab without good effect and were discontinued due
the drowsiness as well as (per ED report) some symptoms of lip
smacking that were thought to be [**2-27**] tardive dyskinesia. He was
originally discharged on tube feeds, but per report has been
tolerating a PO diet. He was brought into the ED today for
further evaluation of these symptoms.
.
In the ED, initial vs were: 98.5 90 130/102 18 99% on room air
Patient was given ativan 2 mg IV x1, Vancomyin 1 gram IV x1,
CFTX 2 grams IV x1, and Dexamethasone 10 mg IV x1. Labs
significant for a WBC of 14.0, ALT of 41, AST of 47, INR of 3.8,
and chemistries WNL. No formal ABG performed, but pH noted to be
7.40 at 4:46 PM. He was noted multiple times by the ED
attendings and residents to have multiple (>3) lethargic
episodes and multiple episodes of myoclonic jerks. The patient
would be responsive afterwards, but somewhat confused per
report, stating he was 'in Brookline'. He got 2 mg of Ativan for
presumed seizure activity and became unresponsive with slight
desaturation requiring BiPAP. Neurology was consulted in the ED
and thought the patient was having myoclonic
jerks/encephalopathy, but exam was clouded by recently receiving
Ativan. Head CT with no acute intracranial process. CTA
demonstrated no PE, LLL aspiration pneumonitis, and a stable
AAA. He was initially going to be taken onto the neurology
service, but due to concern for his unresponsiveness and
possible respiratory compromise, he was admitted to the MICU for
further monitoring. His VS were afebrile 110 25 125/86 100% on
NRB prior to transfer.
.
On the floor, the patient is lethargic and minimally responsive
to vocal or tactile stimuli. IV metoprolol 5 mg q5 min given
upon admission to the floor for AF w/ RVR.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
Atrial fibrillation
Rheumatic Heart Disease complicated by aortic stenosis: s/p
[**Month/Day (2) 1291**]/MVR on [**2125-7-3**]
[**2089**] SBE after dental procedure
[**2095**]'s: colon cancer s/p colectomy
Tonsillectomy
Hypoacusis, bilateral hearing aids
Colon polyps s/p polypectomy
.
Past Surgical History:
[**2125-7-17**] Trach/PEG,
[**2125-7-3**] [**Month/Day/Year 1291**](tissue)/MVR(tissue)/aortic endarterectomy
Social History:
Patient is widowed with three children. He lives alone. He
worked in sales.
Tobacco: Denies
ETOH: None since [**2085**]
Family History:
Non-contributory. No family history of premature CAD.
Physical Exam:
Physical Exam on Admission to ICU:
Vitals: T: 96.3 BP: 130/85 P: 106 R: 24 18 O2: 97% face tent
oxygen mask
General: elderly M lethargic not responsive to sternal or vocal
stimuli
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP elevated 10 cm at 35'
Lungs: crackles at bases, LLL > RLL
CV: tachycardic, irregularly irregular, normal S1 + S2 with
metallic heart sounds; unable to appreciate murmurs given
tachycardia
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding; PEG c/d/i
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neurologic: depressed LOC, not following commands; normal tone
in all extremities. 1+ reflexes in biceps, 0+ reflexes in
achilles/patellar tendons BL (symmetric)
Pertinent Results:
[**2125-9-12**] 08:50PM GLUCOSE-117* UREA N-20 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-32 ANION GAP-10
[**2125-9-12**] 08:50PM CK(CPK)-28*
[**2125-9-12**] 08:50PM CK-MB-2
[**2125-9-12**] 08:50PM CALCIUM-8.6 PHOSPHATE-4.5 MAGNESIUM-2.3
[**2125-9-12**] 08:50PM VIT B12-1060*
[**2125-9-12**] 08:50PM TSH-0.96
[**2125-9-12**] 08:50PM WBC-14.0* RBC-4.28*# HGB-12.3* HCT-38.4*
MCV-90# MCH-28.7 MCHC-32.0 RDW-15.5
[**2125-9-12**] 08:50PM PLT COUNT-206
[**2125-9-12**] 06:48PM URINE HOURS-RANDOM
[**2125-9-12**] 06:48PM URINE bnzodzpn-NEG opiates-NEG cocaine-NEG
mthdone-NEG
[**2125-9-12**] 05:34PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2125-9-12**] 05:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2125-9-12**] 05:34PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2125-9-12**] 05:34PM URINE HYALINE-[**7-5**]*
[**2125-9-12**] 05:34PM URINE CA OXAL-OCC
[**2125-9-12**] 04:46PM PH-7.40 COMMENTS-GREEN TOP
[**2125-9-12**] 04:46PM GLUCOSE-108* LACTATE-1.2 NA+-140 K+-4.1
CL--97* TCO2-36*
[**2125-9-12**] 04:46PM freeCa-1.08*
[**2125-9-12**] 04:42PM UREA N-22* CREAT-0.8
[**2125-9-12**] 04:42PM estGFR-Using this
[**2125-9-12**] 04:42PM ALT(SGPT)-41* AST(SGOT)-47* ALK PHOS-85 TOT
BILI-0.9
[**2125-9-12**] 04:42PM LIPASE-23
[**2125-9-12**] 04:42PM cTropnT-<0.01
[**2125-9-12**] 04:42PM ALBUMIN-3.2* CALCIUM-8.8 PHOSPHATE-4.1
MAGNESIUM-2.3
.
Other Notable Labs:
[**2125-9-14**] 02:22AM BLOOD ALT-33 AST-34 LD(LDH)-294* AlkPhos-65
TotBili-0.3
[**2125-9-13**] 09:33AM BLOOD CK(CPK)-25*
[**2125-9-13**] 09:33AM BLOOD CK-MB-3 cTropnT-<0.01
[**2125-9-14**] 02:22AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.1 Mg-2.2
[**2125-9-12**] 08:50PM BLOOD VitB12-1060*
[**2125-9-12**] 08:50PM BLOOD TSH-0.96
[**2125-9-14**] 02:32AM BLOOD freeCa-1.19
.
Discharge Labs:
[**2125-9-19**] 09:00AM BLOOD WBC-9.8 RBC-3.95* Hgb-11.0* Hct-34.7*
MCV-88 MCH-27.9 MCHC-31.9 RDW-15.8* Plt Ct-158
[**2125-9-19**] 09:00AM BLOOD PT-26.1* PTT-33.8 INR(PT)-2.5*
[**2125-9-19**] 09:00AM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-138
K-4.0 Cl-100 HCO3-33* AnGap-9
[**2125-9-19**] 09:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.2
.
ECG [**2125-9-12**]: Atrial fibrillation with a mean ventricular rate of
110. Non-specific intraventricular conduction delay. Left axis
deviation with probable left ventricular hypertrophy. Compared
to the previous tracing of [**2125-7-3**] multiple abnormalities as
previously noted persist without major change.
.
CT Head w/o contrast [**2125-9-12**]: No acute intracranial process.
Low-attenuating lesions in the periventricular white matter,
most likely represent sequelae of chronic small vessel ischemic
disease.
.
Chest CTA [**2125-9-12**]: 1. Bilateral pleural effusions with
perifissural consolidation/atelectasis. Peribronchovascular
thickening extending into the posterior segment to the left
lower lobe is concerning for aspiration.
2. Stable ascending aortic aneurysm. Stable dilation of the
aortic arch as
well as the distal aspect of the thoracic aorta. 3. Cardiomegaly
with biatrial enlargement. 4. No pulmonary embolism.
.
[**Month/Day/Year 5283**] US [**2125-9-13**]: 1. No evidence of cholecystitis or biliary
obstruction.
2. Bilateral, right greater than left small pleural effusions.
3. Multiple bilateral renal cyst again seen.
.
TTE [**2125-9-14**]:The right atrium is moderately dilated. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is moderately depressed (LVEF= 30-35%). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. A bioprosthetic aortic valve prosthesis is
present. The prosthetic aortic valve leaflets appear normal The
transaortic gradient is normal for this prosthesis. Trace aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The prosthetic mitral valve leaflets are thickened.
The transmitral gradient is normal for this prosthesis. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: No vegetations seen, but current study cannot
exclude prosthetic valve endocarditis. Depressed left
ventricular systolic function.
.
TEE [**2125-9-18**]: Moderate to severe spontaneous echo contrast is
seen in the body of the left atrium. No mass/thrombus is seen in
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. LV systolic function
appears depressed. There are simple atheroma in the descending
thoracic aorta. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The prosthetic mitral leaflets appear normal. The
transmitral gradient is normal for this prosthesis. No mass or
vegetation is seen on the mitral valve. There is a moderate
sized pericardial effusion. IMPRESSION: No valvular vegetations
seen. Normally-functioning bioprosthetic aortic and mitral
valves.
Brief Hospital Course:
81yo male with history of rheumatic heart disease s/p St. [**First Name5 (NamePattern1) 1525**]
[**Last Name (NamePattern1) 1291**] and tissue MVR in [**6-/2125**], afib on coumadin, and systolic
heart failure who presented to ED from rehab with
lethargy/altered mental status.
#. Respiratory Failure: Patient developed acute hypercarbic
respiratory failure secondary to lorazepam administration in ED.
He was transferred to ICU for further care, but did not require
intubation. He has severe OSA, and was seen by sleep medicine
while in ICU. Unable to complete study as patient could not
tolerate BiPAP, but patient will need sleep medicine follow-up
and repeat sleep study as outpatient. The patient's respiratory
status improved, and he was stable for transfer to the floor on
[**2125-9-14**]. The patient was unable to tolerate CPAP, and therefore
was kept on oxygen via nasal cannula at night. He was not given
any further sedating medications except in the setting of his
TEE. All sedating meds in the outpatient setting should be
avoided or minimized as possible.
.
#. Enterococcal bacteremia: Blood cultures drawn on admission
positive for enterococcus sensitive to vancomycin and ampicilin.
He was initially on vancomycin, then switched to
ampicillin/gentamicin per ID consult recommendations. He
required ampicillin desensitization in ICU setting given his h/o
penicillin allergy. A TEE on [**2125-9-18**] did not reveal the presence
of any valvular vegetations. However, per ID recs the patient
should still complete a course of antibiotics that would treat
endocarditis, especially given his [**Date Range 1291**]/MVR. CT surgery was
following, and there was no need for surgical intervention given
the TEE findings. The patient will be on ampicillin until
[**2125-10-28**], and gentamicin for synergy until [**2125-9-29**]. He had a PICC
placed on [**2125-9-19**] for continued antibiotic therapy. All
surveillance blood cultures drawn since [**2125-9-12**] were negative to
date at time of discharge. The patient remained afebrile and
was hemodynamically stable.
.
#. Altered mental status: The patient was found to have
enterococcal bacteremia, and delirium in setting of infection
was likely the primary contributing factor to his altered mental
status. Also probable contributing factors include chronic CO2
retention, severe OSA, medication effects, and prolonged
hospital course. Head CT on admission did not show any acute
intracranial process. No other source of infection, including
PNA or UTI, was identified. At time of discharge, patient's
mental status continued to wax and wane. He was oriented to
person and place, and able to follow some commands.
.
#. s/p St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] and tissue MVR: Given valves, goal INR is
2.5-3.5. The patient's INR was trended and coumadin dose was
adjusted accordingly. Coumadin held for period in setting of
supratherapeutic INR, then restarted. INR was also briefly
subtherapeutic, and patient was placed on heparin gtt during
this time to bridge back to a therapeutic INR on coumadin. INR
was at goal (2.5) on day of discharge, and heparin gtt had been
stopped. INR should continue to be monitored, and coumadin dose
adjusted accordinly. As above, no evidence of valvular
vegetations was seen on TEE [**2125-9-18**].
.
#. Atrial fibrillation: Patient's home dose of metoprolol was
titrated up to 100mg PO TID, given frequent episodes of
tachycardia to 120s. Patient was asymptomatic and
hemodynamically stable during these episodes. He was continued
on coumadin as above for both his a fib and [**Month/Day/Year 1291**]/MVR.
.
#. Chronic systolic heart failure: TTE on [**2125-9-14**] showed LVEF of
30-35%. Patient appeared euvolemic for much of hospital course.
He was on furosemide 20mg daily prior to admission, and this
medication should be restarted in outpatient setting if patient
develops hypervolemia and pulmonary edema. Patient was continued
on ACE inhibitor and beta blocker. Lisinopril dose is currently
5mg daily, this can be up-titrated if BP will allow in
outpatient setting.
.
#. Hypertension: The patient was continued on metoprolol,
lisinopril as above. Furosemide may be restarted as outpatient
if patient develops hypervolemia or becomes more hypertensive.
.
#. Hyperlidipemia: The patient was on simvastatin 10mg daily
prior to admission, and this was re-started prior to discharge.
This medication was briefly held in setting of elevated
transaminases, however was resumed as transaminases trended down
to normal levels. Etiology of elevation in transaminases
unclear. [**Name2 (NI) 5283**] US on [**2125-9-13**] was unremarkable.
.
#. Nutrition: Patient has PEG tube in place, but has not been
using since prior to admission. He is able to tolerate PO
intake, but should be monitored on aspiration precautions.
Medications on Admission:
ATORVASTATIN 10 mg PO QHS
FUROSEMIDE 20 mg PO daily
IPRATROPIUM BROMIDE [ATROVENT HFA] 17 mcg INH 2 puffs QID:PRN
LANSOPRAZOLE 30 mg PO daily
LISINOPRIL 5 mg PO daily
METOPROLOL TARTRATE 75 mg PO BID
POTASSIUM CHLORIDE 10 mEq PO once a day
WARFARIN [COUMADIN] 4 mg PO daily (dosed based on INR - held
since [**2125-9-11**] due to elevated INR of 4.0)
ASPIRIN 81 mg PO daily
MULTIVITAMIN 1 tablet PO daily
Discharge Medications:
1. Ampicillin Sodium 2 gram Recon Soln [**Month/Day/Year **]: One (1) Recon Soln
Injection Q4H (every 4 hours) for 39 days: last day [**2125-10-28**].
2. Warfarin 2 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Once Daily at 4
PM.
3. Lisinopril 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
4. Gentamicin in NaCl (Iso-osm) 80 mg/50 mL Piggyback [**Month/Day/Year **]: One
(1) Intravenous every twelve (12) hours for 10 days: last day
[**2125-9-29**].
5. Metoprolol Tartrate 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO TID
(3 times a day).
6. Senna 8.6 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
7. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, hypoxia.
11. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary Diagnosis:
1. Bacteremia
.
Secondary Diagnoses:
1. Delirium
2. Atrial fibrillation
3. Chronic systolic heart failure
4. Hypertension
5. Hyperlipidemia
6. Aortic valve and mitral valve replacements
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with increased tiredness and
confusion. We found you have an infection in your blood. You
were initially admitted to the ICU because you were having
trouble breathing, but your breathing improved and you were
stable to be on the general medicine floor. An ultrasound of
your heart did not show any infection on your heart valves. We
treated you with antibiotics, and you will need to continue
these antibiotics after you leave the hospital.
.
Please take all medications as directed. Please keep follow-up
appointments as scheduled. You should follow-up with Dr.
[**Last Name (STitle) 1147**], and also follow-up with sleep medicine about repeating
a sleep study.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1147**] after you leave rehab.
.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2125-9-27**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
|
[
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"421.0",
"790.92",
"V12.72",
"327.23",
"V10.05",
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"288.60",
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"V45.72",
"507.0",
"401.9",
"V42.2",
"427.31",
"416.8",
"E939.4",
"428.0",
"428.22",
"518.81",
"293.0",
"441.4",
"041.04",
"V58.61",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"88.72",
"99.12"
] |
icd9pcs
|
[
[
[]
]
] |
17795, 17869
|
11187, 13286
|
304, 353
|
18118, 18118
|
5881, 7768
|
19020, 19435
|
5014, 5070
|
16514, 17772
|
17890, 17890
|
16084, 16491
|
18295, 18997
|
7784, 11164
|
4748, 4859
|
5085, 5862
|
17946, 18097
|
234, 266
|
409, 4367
|
17909, 17925
|
18133, 18271
|
4411, 4725
|
4875, 4998
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,551
| 119,989
|
38615
|
Discharge summary
|
report
|
Admission Date: [**2131-3-25**] Discharge Date: [**2131-4-10**]
Date of Birth: [**2052-5-8**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Percocet
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Possible CSF Leak
Major Surgical or Invasive Procedure:
Lumbar Drain Placement [**2131-3-26**].
History of Present Illness:
This is a 78 year old patient that underwent a L4-L5 [**Location (un) **]
procedure and decompression of L5-S1 with repair of L [**4-9**]
meningocele and L5-S1 posterior stabilization with pedicle
screws on [**2131-3-20**]. Postoperatively the patient has been
experiencing severe headache that he describes as a level 9 on
[**1-14**] pain
scale. The patient also reports minimal low back pain with
movement in bed at his incisional site. The patient denies
blurred vision, nausea, vomiting, weakness, numbness, tingling
sensation.
[**Hospital **] Hospital suspected a CSF leak and transferred the
patient here at the request of the patients daughter for further
care.
Past Medical History:
COPD, HTN, RH, hypothyroidism, s/p gall bladder surgery,
stenosis L5-S1
Social History:
Non-Contributory
Family History:
Non-Contributory
Physical Exam:
PHYSICAL EXAM on Admission:
O: T:98.4 BP: 144/67 HR:63 R:18 O2Sats: 99% RA
Gen: comfortable, NAD.
HEENT: Pupils: 3-2mm EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5
L 5 5 5 5 5 5
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Proprioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
Pertinent Results:
ADMISSION LABS:
[**2131-3-25**] 07:05PM GLUCOSE-97 UREA N-19 CREAT-1.2 SODIUM-135
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14
[**2131-3-25**] 07:05PM WBC-12.5* RBC-3.66* HGB-11.0* HCT-32.9*
MCV-90 MCH-30.0 MCHC-33.4 RDW-14.9
[**2131-3-25**] 07:05PM PT-11.7 PTT-24.0 INR(PT)-1.0
Notable labs
INRs:
[**2131-4-6**]: 1.2, PT 14.2
[**2131-4-5**]: 1.2
[**2131-4-4**]: 1.1
all others prior 1.1
Discharg labs:
_______________________________________________________
IMAGING:
[**2131-3-25**] CXR
Apparent asymmetrical left apical thickening, difficult to
assess due to technical factors.
.
[**2131-3-26**] MR [**Name13 (STitle) **]
IMPRESSION:
1. There is a hyperintense fluid collection effacing the
posterior thecal sac at the levels of L4-S1. This likely
represents a CSF leak from a dural tear.
2. There is extension of the collection into the posterior
subcutaneous tissues via a small tract.
3. The fluid collection is most conspicuous on the T1
post-contrast images with minimal rim enhancement, but lack of
other typical features of abscess formation.
4. Multilevel degenerative changes and disc bulges with
narrowing of the neural foramina on the left side at L3-L4 and
on the right more than on the left at the level of L5-S1.
.
[**2131-3-28**] LENIs
IMPRESSION: No evidence of bilateral lower extremity DVT.
.
[**2131-3-28**] CT chest w/o contrast
IMPRESSION:
1. No apical mass. Small left apical nodule is likely scar, but
it should be monitored on followup CT recommended for multiple
subcentimeter nodules.
2. Moderate chronic bronchiectasis in the upper lobes. without
active
infection.
3. Moderate centrilobular emphysema with upper lobe
predominance.
4. Diffuse mild peripheral paraseptal changes, non-specific,
could represent paraseptal emphysema with wall inflammation or
very early form of interstitial pulmonary fibrosis.
5. Small hiatal hernia. Status post cholecystectomy.
.
[**2131-3-28**] CT l spine
IMPRESSION:
1. Tiny 2 mm radiopaque focus, noted at the level of S1-2,
posteriorly along the left side likely subdural/epidural in
location. This most likely represents the fractured tip of the
prior lumbar drain.
2. Intact new lumbar drain noted, the tip at the level of L4 as
described above.
3. Multilevel degenerative changes with small amount of air as
described above in the anterior epidural space at L4 level,
which likely relate to the recent procedure along with
degenerative changes. Followup can be considered, to assess
resolution.
4. Postsurgical changes at L4, L5 and S1 levels. Limited
assessment of the intrathecal and neural structures as well as
posterior spinous soft tissues for fluid collections, etc. If
this information is desired, MR of the lumbar spine can be
considered if there is no contraindication.
5. Marked atherosclerotic vascular calcification involving the
abdominal aorta and its branches; small 5 mm intermediate signal
intensity focus in the left kidney medially, which needs further
evaluation with ultrasound. Other details as above.
6. Abnormal appearance of the left ilium, as described above.
Further
evaluation with PXR/CT Pelvis can be considered.
.
[**2131-3-31**] CXR
IMPRESSION: Small focal area of increased density at the right
base, which could represent pneumonia. Mild compression
deformity of a mid thoracic vertebral body, most likely old.
.
[**2131-4-1**] CT head w/o contrast
IMPRESSION:
1. No intracranial hemorrhage or edema. No fracture.
2. Paget's disease of the skull.
.
[**2131-4-2**] CT CHEst with contrast
IMPRESSION:
1. Extensive pulmonary emboli involving lobar, subsegmental, and
subsegmental branches bilaterally. No secondary findings of
right heart strain.
2. New ground glass opacity and consolidation within the right
lower lobe, which may reflect an evolving infarct or pulmonary
hemorrhage.
3. Multiple bilateral pulmonary nodules, without short interval
change from [**2131-3-28**].
4. Centrilobular emphysema with an upper lobe predominance.
5. Subpleural-based interstitial fibrosis predominantly within
the lower lobes.
.
[**2131-4-3**] ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is moderately dilated.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Preserved global left ventricular systolic function.
Preserved right ventricular function. Mild aortic dilation. Mild
pulmonary hypertension.
.
[**2131-4-3**] CXR portable
In comparison with the study of [**3-31**], there is some continued
hyperexpansion of the lungs. Small areas of increased
opacification at the bases are again consistent with some
atelectasis and possibly small right effusion, though the right
costophrenic angle is more sharply seen. No evidence of vascular
congestion or acute focal pneumonia.
.
[**2131-4-3**] LENIs
1. No evidence of deep venous thrombosis involving the bilateral
lower extremity venous systems.
.
[**2131-4-4**]: CXR
As compared to the previous examination, there is unchanged
massive
pulmonary emphysema. The pre-existing minimal opacities at the
bases of the right lung are better visible than on the previous
examination, in case of persistent [**Last Name (LF) **], [**First Name3 (LF) **] atypically
distributed infectious process should be considered. No evidence
of pleural effusions. Normal size of the cardiac silhouette. No
hilar or mediastinal abnormalities.
Brief Hospital Course:
Neurosurgical course summary:
Mr. [**Known lastname 2412**] was admitted to the NSurg service, where he was kept
HOB <30 degrees and on bedrest. The decision was made to place a
lumbar drain to enable and control the draining of the CSF.
This was done under interventional Radiology. During the
procedure, the tip of the drain catheter broke off intradurally,
and was unable to be retrieved. The patient therefore had a
replacement of the drain at L3. He drained 15cc/hour and
remained HOB flat. His headache persisted, and his neurological
exam remained stable.
He had LENIS on [**3-28**] and these were negative. the Lumbar drain
was removed on [**3-29**] and his HOB was gradually elevated. He had a
slow decline in his headache and she HOB was slowly elevated. He
we OOB with PT/OT, and was ambulating very well. However, on
the afternoon of HD 11, while ambulating with PT, he became
acutely Short of Breath, hypoxic to low 80s, and hypotensive at
78/42. A stat CTA Chest was performed, which demonstrated
inumerable Pulmonary Emobli in all lung lobe fields. He was
immediately started on a Heparin gtt, and was sent to the ICU.
He remained hemodynamically stable with a BP > 110, and Oxygen
saturations in the high 90s with NC.
On [**4-3**], he was determined to be stable, and transferred to the
neurosurgery floor. While in the ICU, he was noted to have
subtle difficulty with swallowing. A video swallow evlauation
was ordered, and swallow consultation obtained, which were all
normal. He was started on coumadin [**2131-4-3**] On [**4-4**], he was
noted to have a singular episode of 2 drops of blood on the
toilet paper. Physical exam revealed hemorrhoids and Stool Guiac
was negative.
The patient was transferred to the medical service on [**2131-4-4**]:
Below is the hospital course by problem
Patient is a 78 y/o M with history of hypothyroidism who
intially had L5-S1 decompression [**2131-3-20**] complicated by dural
tear with CSF leak requiring lumbar drain [**2131-3-26**] - [**3-29**]. His
course has since been complicated by PEs and Acute renal
failure.
1. Pulmonary Embolism: Bilateral and numerous. As notived above,
the patient had LENIs several days prior to the diagnosis
negative for DVTs and day of diagnosis, LENEis negative as well.
Likely pelvic DVT. Patient with DVT in the distant past, about
15 years ago, but reports that this was after trauma, so
provoked. The patient was started on heparin gtt on [**2131-4-3**]
while on the neurosurgical service. PTT goal for the first day
was 40-60, and on [**2131-4-4**], increased to 60-80. He was started on
coumadin on [**2131-4-3**], given 5mg. on [**2131-4-4**], he was given 7.5mg,
and the 5mg daily from there. On [**2131-4-5**] PM, the heparin was
switched to Lovenox to bridge to therapeutic INR. He was seen by
Hematology while here, they agree with the plan and recommend
hypercoaguable work up as an outpatient. Factor V leiden was
sent, but was pending on discharge.
- Lovenox and Coumadin should be overlapped by atleast 2 days
after the INR is therapetic.
- VNA will check INRs and communicate results with PCP.
[**Name Initial (NameIs) **] PAtient will follow up with PCP [**Name Initial (PRE) **] week after discharge.
Acute Renal Failure: Intermittent while hospitalized, Likely
pre-renal, resolved easily wit with fluid bolus
- Patient will hold lisinopril until f/u with PCP
Bright Red Blood per Rectum: Likey from hemorrhoid seen on
physical exam. He had had this before. Patient guaiac negative
brown stool. Hct stable
Anemia: slow drift during hospitalization. max 35, Guaiaic
Negative
- iron studies: consistent with anemia of chronic disease
CSF leak, S/p Lamenectomy, Headache: Please see neurosurgical
portion of summary for more details on this. CSF leak resolved.
lamenectomy incision healing well. Patient continues to have
headaches, likely from low CSF volume after leak
- Vicodin for headache
Orthostatic Hypotension: patient orthostatic prior to transfer
to SICU, not orthostatic prior to discharge.
- will hold lisinopril until f/u with PCP
COPD: No diagnosis, never had had symptoms of this, but seen on
CT scan
Hypothyroidism:stable
- continue 100mcg levothyroxine
Dysphagia: long [**Last Name **] problem. patient feels like he
occassionally chokes on food. bedside eval normal.
- video swallow: IMPRESSION: Gross penetration with thin
liquidS. No aspiration.
- follow S/S team consult recs
- will f/u with GI doctor as outpatient
Nodules seen on CT scan: Will need follow up CT in 3 months , to
be followed by PCP.
Medications on Admission:
Fioricet-2 tabs q 6 hours, Dilaudid 2-4 mg po q 3 hours
PRN,senna, Ambien 5 mg po q hs, Dulcolax, Levoxyl .1 poqd,
Zestril 10 mg po qd, Prilosec 40 mg po
qd, prednisone 5 mg po qd, Tylenol
Discharge Medications:
1. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain: [**Month (only) 116**] cause drowsiness.
Disp:*20 Tablet(s)* Refills:*0*
5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day: Please do not take at the same
time as Levothyroxine.
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for headache.
12. Outpatient Lab Work
Please have your blood drawn on [**4-12**] to check your PT, PTT,
INR, Creatinine level. PLease have the results faxed ATTN: Dr.
[**Last Name (STitle) 23430**] at [**Telephone/Fax (1) 80019**].
13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Dural Tear
DVT
Pulmonary Embolus
Discharge Condition:
Neurologically Stable
Discharge Instructions:
You were transferred to [**Hospital1 18**] with a CSF leak. You had a drain
placed in your lumbar spine and the leak stopped. While you were
here, you were diagnosed with a pulmonary embolism. For this you
were treated intially with Heparin gtt, and then transitioned to
Lovenox in the hospital. You were also started on a blood
thinning medication called Coumadin, your Coumadin levels were
therapeutic before leaving the hospital. Your shortness of
breath is slowly improving. You have had a headache, which is
improved since you intially got here, but still present. The
pain improves on Vicodin. Your kidney function was also
increased which is likely because you were slightly dehydrated,
please drink plenty of fluids at home.
??????Do not smoke.
??????Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery
??????No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
??????Limit your use of stairs to 2-3 times per day.
??????Have a friend or family member check your incision daily for
signs of infection.
??????Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
??????Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Senna while taking narcotic
pain medication.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
??????Pain that is continually increasing or not relieved by pain
medicine.
??????Any weakness, numbness, tingling in your extremities.
??????Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
??????Fever greater than or equal to 101?????? F.
??????Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Please take all your medications as prescribed. The following
changes were made to your medication regimen:
We started you on 5 NEW medications:
1. Please take Coumadin 7.5mg everyday, your Primary doctor may
change this dose based on your blood thinning level
2. You can take Zofran 4mg every 8 hours as needed for nausea
3. You can take Vicodin 5-500mg three times a day as needed for
headaches. If you dont have a headache you dont need to take
this medication.
4. You can take Ambien 5mg at bedtime for insomnia as needed.
5. You can take Senna 8.6mg twice a day as needed for
consiptation
We STOPPED one of your medications:
1. Please DO NOT take your Lisinopril until you see Dr. [**Last Name (STitle) 23430**]
next week.
Please have your blood drawn on [**4-12**] to check your kidney
function and your blood thinning level.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 85821**] on [**4-16**]
at 1:30.
Department: RADIOLOGY
When: TUESDAY [**2131-5-15**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2131-5-15**] at 1:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"458.0",
"585.9",
"403.90",
"584.9",
"285.29",
"244.9",
"997.09",
"415.19",
"496",
"787.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
14136, 14180
|
7799, 12352
|
297, 339
|
14257, 14281
|
1925, 1925
|
17174, 17777
|
1187, 1205
|
12592, 14113
|
14201, 14236
|
12378, 12569
|
14305, 17151
|
1220, 1234
|
240, 259
|
367, 1041
|
1942, 7776
|
1248, 1474
|
1489, 1906
|
1063, 1137
|
1153, 1171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,556
| 153,790
|
38862
|
Discharge summary
|
report
|
Admission Date: [**2101-5-25**] Discharge Date: [**2101-6-1**]
Date of Birth: [**2043-2-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy with mechanical tumor debridement and excision and
argon plasma coagulation
History of Present Illness:
58 year old male with widely metastatic melenoma unresponsive to
IL-2, s/p cycle 1 dacarbazine [**5-11**], being transferred from OSH
for management of worsening dyspnea and ongoing UGI bleed. Prior
to transfer he was ruled out for pulmonary embolism, and the day
of transfer he vomited guaiac positive emesis.
Mr. [**Known lastname **] presented to OSH [**5-24**] with nausea, vomiting and dyspnea.
He reports over the last two days worsening nausing and new
onset of vomiting. Also constipation for 2 days. He reports
baseline dyspnea that over the past 3 days has worsened such
that he can only walk 10 feet until he has to stop and rest. No
dyspnea at rest, no orthopnea, no chest pain, no diaphoresis. He
was hospitalized one week ago for recieve 2 units pRBCs for his
slow UGI bleed.
Review of sytems:
(+) Per HPI. + drenching night sweat last night with chills. +
weight loss. + sharp/stabbing RUQ pain. + 1 day of urinary
hesistancy +severe fatigue
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied cough. Denied chest pain or
tightness, palpitations. Denied diarrhea. No urinary or fecal
incontinence. No dysuria. States no black stools for 1 week.
Past Medical History:
HTN
COPD - used albuterol inhaler
Metastatic Melenoma: symptoms [**12-29**] melena
DX:[**2-4**] after UGI Bleed when endoscopy showed gastric mass, 2
moles on back bx and confirmed as melenoma.
STAGING: CT Torso - multiple bilateral pulmonary nodules with a
dominant mass in the LLL. LLL mass biopsy c/w melanoma. PET-CT
on [**2101-2-21**] was notable for FDG-avid adenopathy in the mediastinum
and left suprahilar region, multiple bilateral lung nodules,
multiple liver lesions, a lymph node adjacent to the pancreatic
head, and an "extremely" avid lesion in the greater curvature of
the mid-body of the stomach. There was also FDG avidity in
C2/C3 posterior elements, the right medial ilium, and the left
inferior pubic ramus. An MRI of the brain was negative.
TREATMENT: HD IL-2 here at [**Hospital1 18**] from [**Date range (1) 86250**] (received 8
of 14 doses) and [**Date range (1) 86251**]/10 (received 9 of 14 doses). Limited
by acute renal failure and dyspnea. Failed. Tumor progressed.
Started [**2101-5-11**] Dacarbazine, cycle 1.
Social History:
Partner, [**Name (NI) **]. Quit smoking [**12/2100**], prior > 100 pack smoker.
Prior alcohol use up to 12 cases of beer per week, now none.
Prior to illness was the call center manager of a catalog
company.
Family History:
Mother - lung cancer, death 30s, she was a smoker
Physical Exam:
ON ADMISSION
Afebrile, HR 120, BP 110/70, RR 18, O2sat 96% RA
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t)
Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Percussion: Dullness : left posterior lung
field), (Breath Sounds: Clear : anteriorly, Diminished:
posterior/lateral, Absent : left posterior lung field, base
RLL), chest wall inferior to left nipple palpable subcutaneous
nodule approx 1 cm
Abdominal: Soft, Bowel sounds present, Tender: RUQ, LUQ, firm,
tender liver edge 3 cm below ribs, subcutaneous masses palpable,
2 RUQ ( > 4 cm each), one midline in pubic area, on to left of
midline by umbilicus
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash: , 2 scars right upper lateral back,
hypopigmented with surrounding sm black round satellite lesions
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, reason for
admission, date, Movement: Purposeful, Tone: Normal, [**5-25**] hip
flexors, biceps symettric. intact heel to shin and [**Doctor First Name **].
Pertinent Results:
OSH Labs:
[**5-25**]
Na 133
K 5.4
Cl 94
Co2 25
BUN 12
Cr 0.81
BG 100
AST 73
ALT 73
Tbili 0.9
Alk Phos 600
GGT 339
Albumin 2.6
INR 1.38
WBC 13
HCT 33 (baseline 30-35) at 1400 [**5-25**]
PLT 437
OSH Studies:
6 minute walk, resting O2 sat 98%, trending O2 sat 96%, resting
HR 103, trending HR 117, walked 100 feet.
OSH Images:
ECHO [**2101-5-25**]: EF 55-60%, LA mild dilated with diameter 43mm,
mild MR, mild TR, est PA pressure 22 mmHg, no pericardial
effusion.
CTA [**2101-5-21**]: No CT evidence of pulmonary embolus. Subcarinal
soft tissue mass 8 *11 cm compressing left lower lobe bronchus
with left lower lobe collapse. Progression from CT [**2101-2-4**]
when mass was maximally 5.2 cm. Multiple pulm nodules and
perihilar lymph nodes increased in size from prior. New chest
wall nodules worrisome for metastatic deposits.
ON ADMISSION:
[**2101-5-25**] 10:11PM BLOOD WBC-11.0 RBC-3.77* Hgb-9.5* Hct-31.0*
MCV-82 MCH-25.1* MCHC-30.6* RDW-19.2* Plt Ct-430
[**2101-5-25**] 10:11PM BLOOD Neuts-81.6* Lymphs-11.4* Monos-6.1
Eos-0.9 Baso-0.1
[**2101-5-25**] 10:11PM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-133
K-4.9 Cl-97 HCO3-23 AnGap-18
[**2101-5-25**] 10:11PM BLOOD ALT-61* AST-65* AlkPhos-547* TotBili-0.9
[**2101-5-25**] 10:11PM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.7 Mg-1.9
[**2101-5-25**] 10:11PM BLOOD Lipase-18
[**2101-5-26**] ECG: Sinus tachycardia, rate 106. Possible inferior
myocardial infarction of
undetermined age. Generalized non-specific repolarization
abnormalities.
Compared to the previous tracing of [**2101-3-28**] normal sinus rhythm
has given way to
sinus tachycardia.
[**2101-5-26**] CXR: Newly occurred partial left lung atelectasis with
suspicion of central bronchial metastatic occlusion. Subsequent
shift of the heart and the mediastinum. Increase in size of
pre-existing right lung metastasis.
[**2101-5-30**] CXR: Persistent but mildly improved left lower lobe
collapse with pleural effusion. No evidence of pneumothorax.
[**2101-5-30**] Left Main Bronchus Tumor Pathology: Pending
Brief Hospital Course:
In the MICU: 58 year old male with widely metastatic melenoma
admitted from OSH, determined to be hemodynamically stable,
treated with supportive care for his worsening dyspnea, fatigue,
RUQ pain from liver metastasis, and new onset nausea and
vomiting in setting of ongoing slow UGI bleed. Patient evaluated
by interventional pulmonary and transferred to the floor for
ongoing medical management and potential placement of stent in
left bronchus.
On the floor:
#. Dyspnea: He had progressive worsening dyspnea felt to be due
to metastatic melanoma. He underwent bronchoscopy and was found
to have a left mainstem endobronchial tumor. It was debridement
as possible but stents were not able to be put in. His
follow-up chest xray showed increased aeration of the left lower
lobe and the patient had subjective improvement in his dyspnea,
although still had difficulty walking or exerting himself
without become short of breath.
#. UGI Bleed: He has a known melenoma metastasis eroding into
his stomch lining. He had ongoing guaiac positive melenotic
stools during this admission. He had a slow hematocrit drop
felt to be a very slow upper GI bleed. He remained
hemodynamically stable. He was given 1 unit of PRBC's prior to
discharge. He was continued on his home PPI.
#. Nausea/Vomiting: He had intermittent nausea and vomiting felt
to be irritation from his bleeding in his stomach or possibly
other tumor irritation. He was given prn zofran and compazine.
#. Urinary Hesistancy: He reported urinary hesitancy
intermittently that was felt to be related to narcotic use. It
resolved without intervention.
#. RUQ Pain: Likely related to the extensive tumor burden in his
liver. He was started on oxycontin and continued on his home
oxycodone.
#. Metastatic Melenoma:He was given one dose of Taxol on the day
of discharge after his bronchoscopy. His prognosis was
discussed with him extensively and he is transitioning to
hospice care. However, he wanted to try one more round of
chemotherapy to possibly prolong his life and alleviate his
symptoms.
#. Tachycardia: He had persistent tachycardia felt to be due to
underlying malignancy and pulmonary stimuli. He was ruled out
for PE on OSH CTA and had no effusion on OSH echo.
#. Fever: He had low grade fevers for the last 3 days of
hospitalization. He had no clear source of infection, but there
was some concern for post-obstructive pneumonia given his known
LLL obstruction. He was given an 8 day course of levofloxacin.
#. Code Status: He was DNR/DNI during this hospitalization,
which was temporarily reversed for his bronchoscopy.
Medications on Admission:
Medications on Transfer:
Oxycontin 20 mg [**Hospital1 **]
Oxycodone 10 mg q4h: prn: pain
IV morphine 2 mg iv q3h: prn: pain
Ambien 10 mg QHS
Zofran 8 mg IV q8hr
Compazine 10 mg PO q6h: prn: nausea
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
4. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
5. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety/nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Metastatic melanoma
Left lower lobe collapse due to metastatic melanoma
Upper Gastrointestinal Bleed
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 due to shortness of breath.
It was felt that you are short of breath because you have
melanoma in your lungs that is compressing and invading your
airways. You were taken for a bronchoscopy by the
interventional pulmonologists. They cleaned out some of the
disease from your airways and your breathing improved. However,
they were unable to put a stent in your airway.
You also have slow bleeding from your GI tract, likely related
to the melanoma that is in your stomach. Your intermittent
nausea and abdominal pain is felt to be related to this
bleeding, as well as your black stools. Your blood count
decreased slightly during this admission and you were given a
unit of blood prior to discharge.
You also had low grade fevers and were started on an antibiotic
for possible pneumonia.
Changes to your medications:
ADDED levofloxacin 750mg by mouth daily for 10 days
ADDED OxyCONTIN 20mg by mouth every 12 hours
Followup Instructions:
You have the following appointments scheduled in follow-up:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, Floor 9
Phone: [**Telephone/Fax (1) 22**]
Date/Time: [**2101-6-7**] 2:00pm
* Please arrive 30-45 minutes prior to your appointment to have
your blood drawn at [**Hospital Ward Name 23**] 9. You will then go to 7 [**Hospital Ward Name 1826**]
to have chemotherapy at 3:00pm *
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22059**]
Department: Radiation Oncology at [**Hospital3 328**] Cancer Institute
Location: [**Street Address(2) 86252**], [**Location (un) 5871**], MA
Phone: [**Telephone/Fax (1) 22062**]
Date/Time: Wednesday, [**2101-6-8**] at 10:00AM
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
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31,502
| 130,186
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40
|
Discharge summary
|
report
|
Admission Date: [**2174-7-17**] Discharge Date: [**2174-7-20**]
Date of Birth: [**2093-11-17**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Transfused 2 units PRBC.
History of Present Illness:
This is a 80yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]
and recent aortic valvuloplasty [**2174-5-11**] recently hospitalized
for CHF exacerbation requiring intubation(d/c [**2174-7-4**]) who
returns w/SOB x several hours. She notes that she had been
feeling well since her d/c home until this AM. She awoke at 0300
feeling well, but then began to get aggravated thinking about
recent political issues and started to feel SOB as she sat in
bed. Endorses slow onset SOB that persisted causing her and her
husband to call EMS. She received one dose of IV lasix 100mg en
route to the ED to which she put out 100cc of urine. She
endorses having had cough w/sputum production 2 days PTA, but
denies recent fever/chills.
.
In the ED, her initial VS were: 96.4 174/82 HR 109 RR 30s sat
85% 10LNRB. She was briefly on CPAP 5/5 and O2 sat increased to
100%. She was also briefly on a Nitroglycerin drip for her
BP(1hour). She received Aspirin, Furosemide 180mg IV x1 as well
as Vancomycin 1g and Piperacillin-Tazobactam for her
leukocytosis.
.
She and her husband endorse that she has been adherent with her
medications and her 2g sodium diet w/1200-1500 fluid
restriction. They note that her daily weight has been very close
to her dry weight of 109lbs w/just one higher weight last week
of 109.5lbs. She denies chest pain, ankle edema, palpitations,
syncope or presyncope. +2 pillow orthopnea at baseline.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, hemoptysis. She denies exertional
buttock or calf pain. Notes having had dark stools and sometimes
small amount BRBPR last week. None since.
Past Medical History:
CAD--one vessel disease on cath in [**5-/2174**], s/p stent to LCx
Severe AS s/p valvuloplasty [**4-/2174**] ([**Location (un) 109**] from 0.56->0.74; Grad
from 24->12)
Chronic systolic CHF, EF 30-40%
HTN
s/p right nephrectomy [**2165**] for renal cell carcinoma
CRI with Cr 1.3-2.5 over last month, was on hemodialysis for one
month in [**2174-4-14**]
Scoliosis with chronic back pain on vicodin
h/o MRSA from LLE trauma in [**2173-7-14**]
h/o cholelithiasis
osteoarthritis
herpes zoster
Gastritis
h/o H. pylori
Anemia--baseline Hct 26-30
h/o right inguinal herniorrhaphy in [**2156**]
Myositis s/p muscle biopsy at [**Hospital1 112**], possibly related to statin
use
OUTPATIENT CARDIOLOGIST: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**]
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**]
Nephrologist: [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**]
ALLERGIES: statin--myositis
Social History:
Social history is significant for the absence of current tobacco
use; she smoked [**12-15**] PPD from age 18 to age 60. There is no
history of alcohol abuse; she occasionally has wine. Uses a
walker; no recent falls.
Family History:
Father died of a heart valve problem at age 52 and 4 of her
siblings had heart problems (though not valvular disease).
Physical Exam:
VSS, afebrile, O2 sat resting 95% on RA, 87% with ambulation
Gen: NAD
Neuro: Alert and oriented to person, place and time
Pulm: minimal crackles at bases
CV: 4/6 SEM at R 2nd intercostal space, radiates to carotids,
regular rate
GI: +BS, soft, NTND
Ext: No LE edema, 1+ DP pulses
Pertinent Results:
[**2174-7-17**] 06:08AM PO2-69* PCO2-55* PH-7.19* TOTAL CO2-22 BASE
XS--7
[**2174-7-17**] 12:03PM BLOOD Type-ART pO2-39* pCO2-39 pH-7.43
calTCO2-27 Base XS-1
[**2174-7-17**] 06:09AM BLOOD WBC-19.6*# RBC-3.77* Hgb-10.7* Hct-33.0*#
MCV-88 MCH-28.3 MCHC-32.4 RDW-15.8* Plt Ct-579*#
[**2174-7-20**] 05:59AM BLOOD WBC-8.0 RBC-3.64* Hgb-10.6* Hct-31.5*
MCV-87 MCH-29.2 MCHC-33.7 RDW-15.9* Plt Ct-288
[**2174-7-17**] 06:09AM BLOOD UreaN-92* Creat-2.4*
[**2174-7-20**] 05:59AM BLOOD Glucose-86 UreaN-74* Creat-1.9* Na-140
K-3.7 Cl-102 HCO3-25 AnGap-17
[**2174-7-20**] 05:59AM BLOOD Vanco-25.7*
Brief Hospital Course:
Pt was admitted with presumed CHF exacerbation most likely
secondary to increased dietary salt intake and severe aortic
stenosis. Pt was diursed and treated with O2.
CHR Exacerbation:
Patient was diuresed. She was initially started on antibiotics
for question on pneumonia which were then stopped after her
white count normalized.
She was continued on her IV vancomycin course which was started
at a previous hospital stay for strep viridans bacteremia. She
was afebrile for the duration of her stay. The patient was
diursed and treated with oxygen and improved. Pt has prior hx
of GI bleed and had heme positive stools. Her hct remained
stable throughout her hospitalization. She received 2 units of
PRBC for a hct of 23, which was later determined to be near her
baseline of 25.
She was discharged in stable condition to home with home oxygen
as she had ambulatory desats to 87%. She has follow with her
PCP for [**Name9 (PRE) 444**] of her vancomycin levels and follow with with
GI for colonoscopy. She was also instructed to follow up with
her cardiologist for managment of congestive heart failure and
her neprologist for her kidney failure.
Her carvelilol was increased to 21.5mg twice a day and her
neurontin was changed to 300mg every other day. She was resumed
on all her other home medications.
Coronary artery disease:
Pt with history of CAD and has had presious stent. Her cardiac
enzymes were negative and there were no ECG changes. Her ACE-i
was held in the setting of her acute renal failure, she was
continued on her Aspirin and beta blocker.
Aortic Stenosis:
Her severe aortic stenosis was thought to be a contributing
factor to her current CHF exacerbation. She has had a past
valvuloplasty and was determinted not to be a candidate for any
further intervention at this time
Strep viridans bacteremia:
She had a rencent echocardiogram that was negative for
endocarditis. Her blood cultures were negative for her length
of stay. She remained on Vancomycin.
GI bleed: Pt had guiac positive, melanotic stools. She remained
on her PPI and was set up with Dr. [**Last Name (STitle) 79**] as an outpatient for
colonoscopy.
Renal Failure: Baseline Cr appears to be close to 1.6 but her Cr
has been fluctuating up to 2.7 on prior admission. She continues
to have good urine output and her cr trended down.
Medications on Admission:
Aspirin 81 mg daily
Clopidogrel 75 mg daily
Fexofenadine 60 mg [**Hospital1 **]
Hydrocodone-Acetaminophen 5-500 mg 1/2-1 Q4H PRN
Carvedilol 6.25 mg [**Hospital1 **]
Prilosec 20mg daily
Ipratropium Bromide neb Q6H PRN
Lasix 160mg daily
Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous
Q48H for 4 weeks: every other day. 1st day [**6-19**]. Last day [**7-31**].
Gabapentin 100 mg PO TID
Sevelamer HCl 800 mg PO TID
Had been on Losartan 25 mg daily but has been held for ARF
Discharge Medications:
1. Outpatient Lab Work
Please draw vanco level, hct, bun, creatinine on [**7-21**] and
[**7-25**] and call results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**]
phone: [**Telephone/Fax (1) 133**] fax: [**Telephone/Fax (1) 445**]
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
7. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours): You should take this every other day until your
kidney function improves.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed: Do not take if you are very
sleepy.
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-15**] Sprays Nasal
TID (3 times a day) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed.
14. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
Acute renal failure
Aortic stenosis
Strep Viridians Bacteremia
Anemia
Discharge Condition:
Stable
Discharge Instructions:
You had an episode of acute heart failure that was treated with
lasix. Your kidney function had worsened but is now improving.
Please send labs on [**7-21**] and [**7-25**] with results to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**]. He will determine the timing of the vancomycin
doses depending on the vancomycin level. Goal is [**10-3**]. You will
get your vancomycin at Day Care at [**Hospital1 18**] [**Telephone/Fax (1) 446**] on
weekdays. On the weekends you will get the dose on 7 Felberg at
[**Hospital1 18**] phone: [**Telephone/Fax (1) 447**]. Your next vancomycin level needs to
be drawn on [**7-21**] at the [**Hospital Unit Name **] on the [**Location (un) 448**] and you
have an appt on [**7-22**] at Day care at 2pm to get your next
vancomycin dose if your level is <20.
.
Medication changes:
We increased your Carvedilol to 12.5mg twice daily
Your Neurontin was changed to 300mg every other day
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Last
weight here is 107 pounds.
Adhere to 2 gm sodium diet
Fluid Restriction:1500cc/day
Followup Instructions:
Nephrology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:Office will call with a time.
Cardiology:
Provider: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: Monday
[**8-1**] at 3:00pm, [**Hospital Ward Name 23**] [**Location (un) 436**].
Gastroenterology:
Provider: [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**], MD Phone:([**Telephone/Fax (1) 451**] Date/Time:
Wednesday [**9-28**] at 11:15am, [**Hospital Ward Name 452**] Rose Building [**Location (un) 453**].
You are on a waiting list for an earlier appt.
.
Provider: [**Name10 (NameIs) 454**],NINE [**Name10 (NameIs) 454**] Date/Time:[**2174-7-22**] 2:00
Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2174-7-23**] 9:00.Phone: [**Telephone/Fax (1) 22**]
.
Infectious Disease:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2174-7-25**] 10:00
|
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"V45.73",
"790.7",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9004, 9062
|
4385, 6728
|
293, 319
|
9216, 9225
|
3767, 4362
|
10377, 11501
|
3332, 3452
|
7264, 8981
|
9083, 9195
|
6754, 7241
|
9249, 10067
|
3467, 3748
|
10087, 10354
|
234, 255
|
347, 2062
|
2084, 3080
|
3096, 3316
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,708
| 192,989
|
51222
|
Discharge summary
|
report
|
Admission Date: [**2187-12-6**] Discharge Date: [**2187-12-10**]
Date of Birth: [**2141-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Hematemasis
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
This is a 46 year old man with DM2 and a long history of EtOH
abuse who presents with EtOH withdrawal and GI bleeding. He was
seen in the ED on [**12-5**] at around 5pm, at which time he was
intoxicated and hyperglycemic. EtOH level was 200. Hct was 43.
He was discharged home with PCP followup and initially he felt
better at home. His last drink was yesterday around noon. He
began to feel more tremulous and dizzy and ultimately had a fall
at home. He then had an episode of bloody emesis. He describes
about [**1-15**] cups of bright red emesis with some dark red. He the
came into the ED. He denies CP, SOB, abd pain, diarrhea, melena,
BRBPR, dysuria. He continues to complain of tremors. He also
states that he has not taken his insulin or meds or checked his
FS in over a week.
.
From ED he was transfered to MICU. He had a upper endoscopy
which showed grade 3 esophagitis with stigmatat of recent
bleeding. He was treated with [**Hospital1 **] PPI, and h-pylori and hepatits
serologies were sent.
Past Medical History:
type 2 diabetes
alcoholism
eczema
Social History:
Lives with his wife. Denies tobacco use. Drinks 3 pints of rum
and 12 pack of beers per day x multiple years. Has used crack
cocaine in the past, last 3-4 months ago
Family History:
2 uncles and an aunt have diet of EtOH related illness. Mother
died of bone and kidney cancer. Grandmother died of a stroke.
His great-grandfather had DM and his great-grandmother had heart
problems.
Physical Exam:
VS: 96.5, 137/90, 92, 17, 100% on 2L nc
Gen: NAD, slightly tremulous, but appears comfortable
HEENT: PERRL, MM dry, OP clear
Neck: supple, JVP ~5-6cm
Lungs: CTAB
Heart: RRR, no m/r/g
Abd: +BS, soft, NT/ND, no hepatosplenomegaly
Extrem: 2+ DP pulses, no edema
Pertinent Results:
LABS ON ADMISSION:
[**2187-12-5**] 05:00PM WBC-4.2 RBC-4.91 HGB-14.8 HCT-43.0 MCV-88
MCH-30.2 MCHC-34.5 RDW-14.4
[**2187-12-5**] 05:00PM ASA-NEG ETHANOL-200* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-12-5**] 05:00PM ALBUMIN-4.9*
[**2187-12-5**] 05:00PM LIPASE-25
[**2187-12-5**] 05:00PM ALT(SGPT)-202* AST(SGOT)-263* LD(LDH)-270*
ALK PHOS-181* AMYLASE-66 TOT BILI-0.9
[**2187-12-5**] 05:00PM estGFR-Using this
[**2187-12-5**] 05:00PM GLUCOSE-228* UREA N-12 CREAT-1.1 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-27 ANION GAP-21*
.
EGD:
Grade 3 esophagitis in the gastroesophageal junction, lower
third of the esophagus and middle third of the esophagus
compatible with severe exophagitis
No varices seen but small varices may be difficult to detect in
setting of severe esophagitis
Granularity, erythema and congestion in the whole stomach
compatible with gastritis
Granularity, erythema and congestion in the duodenal bulb
compatible with inflammation.
.
[**12-6**] CT head with contrast: IMPRESSION: No evidence for
hemorrhage, mass effect, or skull fracture. Normal study.
.
LABS ON DISCHARGE:
[**2187-12-10**] 06:25AM BLOOD WBC-5.4 RBC-3.83* Hgb-11.5* Hct-34.4*
MCV-90 MCH-30.0 MCHC-33.4 RDW-14.3 Plt Ct-209
[**2187-12-10**] 06:25AM BLOOD Glucose-395* UreaN-12 Creat-1.0 Na-134
K-4.6 Cl-96 HCO3-28 AnGap-15
[**2187-12-8**] 07:49AM BLOOD ALT-82* AST-58* LD(LDH)-180 AlkPhos-116
Amylase-72 TotBili-0.6
[**2187-12-8**] 07:49AM BLOOD Lipase-58
[**2187-12-10**] 06:25AM BLOOD Calcium-10.0 Phos-5.0* Mg-1.7
Brief Hospital Course:
The patient was admitted to the MICU from the ED for hematemasis
and etoh withdrawal. He was transfered from the MICU to the
floor after endoscopy did not reveal bleeding varicies and his
Hct was stable. He continued his etoh withdrawal on the floor,
transitioning from IV to PO valium. He had elevated BS and his
diabetes medications were restarted: Glargine, Glyburine, and
Metformin, bringing his blood sugars under better control.
.
On the floor:
A/P: This is a 46 year old man with DM2 and a long EtOH history
who presents with EtOH withdrawal and hematemesis/upper GI
bleed. His course was complicated by:
.
# Hematemesis/GI bleed: s/p scope revealing grade 3 gastritis at
GE junction.
-continue ppi [**Hospital1 **]
-monitor Hct - stable
-check orthostatis and give fluids if orthostatic - orthostatics
negative
- will have outpatient f/u with liver
.
# EtOH abuse/withdrawal: Heavy alcohol use with last drink wed.
Pt is dizzy on standing, tremulous, tachycardic on initial
presentation to floor from ICU. Continued on CIWA, valium
changed from IV to PO. Currently VS stable, continued mild
tremulousness. CIWA 6 on d/c.
-continued CIWA scale with PO valium prn, while inpt
-continue folate,thiamine
-social work consult was called for substance abuse and they
provided him with lists of treaters in his insurance network.
He refused residential or intensive treatment but seemed
motivated to begin treatment.
.
# DM2: On the floor, he was initially put on outpt metformin
850mg [**Hospital1 **] and lantus 26 u qhs. Non-compliant as outpt. His BS
were consistently elevated in the 300s so [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was
called. Per their recommendations, metformin was stopped,
glyburide was continued and his lantus was increased to 40 U
qhs. He was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] appointment the next day.
.
# FEN: Regular diet, monitor lytes
.
# PPx: PPI IV BID, pneumoboots
.
# Access: PIV x2
.
# Code: Full
.
# Dispo: d/c to home with close outpatient f/u (hepatology,
substance abuse, primary care, [**Last Name (un) **])
Medications on Admission:
lantus 24 units qhs
metformin 850 mg 1 tab po BID
glyburide 5mg 1 tab po BID
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24)
Units Subcutaneous at bedtime.
Disp:*QS * Refills:*2*
7. Lantus 100 unit/mL Cartridge Sig: Forty (40) units
Subcutaneous at bedtime.
Disp:*qs cartridges* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophagitis
Alcohol abuse
Diabetes mellitus - poorly controlled
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
Please take all medications as prescribed. Medication changes
include:
- discontinue metformin
- increase lantus from 24 units at bedtime to 40 units at
bedtime
- take folic acid and thiamine vitamins
- take protonix 40mg 2 times per day
.
Please attend all follow-up appointments.
.
If you experience any nausea, vomiting, lightheadedness, chest
pain, shortness of breath, or any other concerning symptoms
please seek medical attention immediately.
Followup Instructions:
The following appointment has already been made for you:
Please follow up at [**Hospital **] clinic at 8:30AM tomorrow ([**12-11**])
morning.
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Phone: [**Telephone/Fax (1) 2378**] Date/Time: [**2187-12-12**]
01:00 pm
.
Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-12-20**] 9:30
.
Provider: [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], MD (Hepatology/Liver) Phone: [**Telephone/Fax (1) 682**]
Date/Time: [**2187-12-24**] 12:30 [**Last Name (NamePattern1) **]. [**Hospital Unit Name **]
.
It is advised that you attend follow up with the alcohol abuse
resources that you were provided.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"530.12",
"250.02",
"291.81",
"535.01",
"303.91",
"285.1",
"724.2",
"530.82",
"275.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
6787, 6793
|
3700, 5839
|
327, 344
|
6901, 6939
|
2132, 2137
|
7438, 8342
|
1636, 1837
|
5967, 6764
|
6814, 6880
|
5865, 5944
|
6963, 7415
|
1852, 2113
|
276, 289
|
3268, 3677
|
372, 1379
|
2152, 3249
|
1401, 1437
|
1453, 1620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,597
| 146,460
|
8695
|
Discharge summary
|
report
|
Admission Date: [**2151-7-11**] Discharge Date: [**2151-7-19**]
Date of Birth: [**2118-4-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
s/p sinus debridement [**7-13**]
History of Present Illness:
PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) 30443**],[**First Name3 (LF) **] D.
Location: [**Hospital1 **] FAMILY MEDICINE
Address: [**Apartment Address(1) 30444**], [**Hospital1 **],[**Numeric Identifier 14243**]
Phone: [**Telephone/Fax (1) 30445**]
Fax: [**Telephone/Fax (1) 30446**]
33F with presented to [**Hospital1 **] with 6 days facial/[**Doctor Last Name **] pain
and HA. 6 days before presentation, she noticed R facial/jaw
pain associated with pressure in her head. The pain was
described as sharp and constant with no modifying factors. She
went to see her dentist and was told she had TMJ due to teeth
grinding. Her symptoms worsened over the course of a few days.
She also started to notice subjective fevers, mild photophobia,
and neck stiffness, as well as increasing sinus pressure. She
denies vision changes, pain in the eye or with movement of the
eye, sore throat, CP/SOB or cough. She also denied tingling,
numbness. She denies trauma to the area. She lives in the
[**Location (un) 86**] area and denies significant travel or sick contacts, or
obvious rashes. The symptoms progressed to also include mild
swelling around the R eye, no pain, but associated eyelid
drooping. She denies pruritis of the eye.
She presented to the [**Hospital1 **] ED. LP, CXR and CT sinus was
performed. She was given CTX 2g. Given her ? ptosis, she was
transferred to [**Hospital1 18**]. In the ED, T 98.7, HR 69, BP 113/74, RR
16, 98%RA. Given 1L NS and morphine. Evaluated by neurology in
ED. She currently complains of R headache and neck stiffness,
otherwise no change
Review of systems: 10 point review of systems negative except as
listed above.
Past Medical History:
None
Social History:
Lives at home. Married. 3 step-children. Denies tobacco or
drugs. Admits to occasional tobacco use.
Family History:
No history of neurological disease
Physical Exam:
Admission exam:
VS: T 98.7, HR 69, BP 113/74, RR 16, 98%RA
Gen: eyes closed, appears in moderate discomfort, otherwise
awake and alert
HEENT: MMM, OP clear, EOMI without pain, anicteric sclera, no
icterus, mild TTP over frontal and right maxillary sinus. Mild
periorbital soft tissue swelling around R eye, non erythematous
Neck: supple, shotty anterior cervical LAD, mild neck stiffness
but full ROM
Heart: Brady, regular no m/r/g
Lung: CTAB no wheezes or crackles
Abd: soft, mild crampy TTP + BS no rebound or guarding
Ext: warm well perfused no pitting edema
Skin: no obvious rashes detected
Neuro: no focal deficits. R ptosis due to R eye swelling
Discharge physical:
Normal physical exam with all neurologic deficits resolved.
Pertinent Results:
[**Hospital1 **] [**Location (un) 620**] results:
WBC 10.9
Hct 34.2
Plt 210
83N, 6L
Na 138, K 4.1, Cl 99, CO2 29.4, BUN 8, Cr 0.7, Ca 8.7
HCG neg
U/A: small leuk, many bact
Urine cx: >100K E.coli
CSF:
clear, 540 WBC, 87 poly, Gluc 71, prot 28.5
Cx: Neg gram stain, cx negative
CXR:
This is a single frontal view of the chest. The lungs are clear
without infiltrates or effusion. The cardiac silhouette is
normal. The aorta is mildly tortuous. There is minimal
pulmonary vascular redistribution but no pulmonary edema.
IMPRESSION:
NO FOCAL INFILTRATE.
EKG: NSR, nl axis and intervals, no ischemic changes
[**7-11**] MRV/MR head:
IMPRESSION:
1. Acute sinusitis of right maxillary and right ethmoid and
probably right
sphenoid sinusitis on a background of sporadic inflammatory
sinus pattern.
Inflammatory changes in the right cavernous sinus and signal
changes in the right masticator space indicate slow flow and
probably thrombosis of the right cavernous sinus.
2. Lack of opacification of the right superior opthalmic vein
may reflect slow flow or extension of the thrombus. There is
probably some leptomeningeal enhancement along the right
antero-inferior temporal lobe.
[**7-12**] CT sinus:
IMPRESSION:
1. No evidence of abscess.
2. Although evaluation is limited due to timing of contrast,
asymmetric
diminished opacification of the right cavernous sinus,
suspicious for right cavernous sinus thrombosis. Minimal
right-sided proptosis.
3. Extensive paranasal sinus disease as above, right greater
than left.
NOTE ADDED AT ATTENDING REVIEW: There is increasing
opacification of the right paranasal sinuses, along with
continued bulging of the right cavernous sinus.
Brief Hospital Course:
This is a 33 y/o female with no significant PMHx who presented
to [**Hospital1 18**] from [**Hospital1 **]-[**Location (un) 620**] with 6-days of sinusitis, acute onset
proptosis and headache; MRI/MRA in ED showed cavernous vein
thrombosis (likely septic) and CSF cell counts indicated
possible meningitis. Upon diagnosis, she was transferred to
the ICU for close monitoring as she was begun on anticoagulation
and felt to be high-risk. Once stable, she was transferred back
to the floor on [**7-14**].
1. Septic cavernous sinus vein thombosis: This was thought to be
due to her h/o sinusitis and pan-R-sided sinusitis seen on CT
(maxillary, sphenoid, and ethmoid). She was started on
broad-spectrum antibiotics for meningitis as well as septic
cavernous thrombosis, which included ampicillin, vancomycin,
ceftriaxone, flagyl, and acyclovir. The ampicillin and acyclovir
were discontinued and she was maintained on the other
antibiotics (vanc, CTX, and flagyl) to complete a 4 to 6 week
course. A PICC line was placed on [**7-17**]. Infectious diseases
followed the patient closely and she will follow-up as an
outpatient. She likely did not have meningitis given the
negative CSF culture and normal counts, with the exception of
the WBCs, which likely were secondary to inflammation. The
patient was discharged on an extended course of IV antibiotics
via PICC line, with followup in ENT, ID and neurology clinics.
ENT, ophthalmology, and neurology were consulted and assited in
the patient's care throughout the admission. She was immediately
begun on a heparin drip upon admission to the ICU with her PTT
closely monitored. ENT took the patient for sinus debridement
and cultures on [**7-13**], for which her heparin drip was briefly
stopped. Cultures were significant for pan-sensitive E.coli.
Neurology and ophthalmology noted a partial CNIII deficit as
well as a CNVI deficit, which improved and resolved during her
admission. She had nasal packing placed by ENT - to be removed
on [**Month/Year (2) 766**], [**2151-7-19**]. Neurology recommended follow-up brain scans
as an outpatient in 1 month. She was started on coumadin 5 mg in
the ICU to start her 3-month course of anticoagulation. Her INR
will be followed by her PCP.
2. UTI: The patient had a pan-sensitive E.coli UTI discovered at
[**Hospital1 **]-[**Location (un) 620**]. She was appropriately treated for this with the
antibiotics above.
3. Anemia: The patient was found to be anemic at baseline labs.
Iron studies were performed, which showed low serum iron as well
as low TIBC and transferrin indicating anemia of chronic
inflammation. The patient was encouraged to seek follow-up as an
outpatient.
Medications on Admission:
None
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: 1-2 Tablets PO at bedtime: Do not
start taking this medication until Dr [**Last Name (STitle) **] tells you to start
it (after you get home).
Disp:*60 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 weeks.
Disp:*84 Tablet(s)* Refills:*0*
3. Oxymetazoline 0.05 % Aerosol, Spray Sig: Two (2) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for nasal packing for 2 days:
PLEASE STOP TAKING THIS MEDICATION AFTER TWO DAYS (on [**2151-7-21**]).
Disp:*1 bottle* Refills:*0*
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous every twelve (12) hours as needed for line flush for
4 weeks.
Disp:*120 ML(s)* Refills:*0*
5. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1)
3ml Intravenous every twelve (12) hours: Flush for PICC line.
Disp:*120 flushes* Refills:*0*
6. Ceftriaxone 2 gram Piggyback Sig: One (1) dose Intravenous
every twelve (12) hours for 4 weeks.
Disp:*60 doses* Refills:*0*
7. Vancomycin in 0.9% Sodium Cl 2 gram/500 mL Solution Sig: One
(1) dose Intravenous every twelve (12) hours for 4 weeks.
Disp:*60 doses* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
Cavernous sinus thrombosis
Sinusitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear [**Known firstname **],
It was a pleasure to take care of you during your time in the
hospital. As you know, you were admitted with an infected blood
clot in the cavernous sinus. You were initiated on antibiotics
through an IV, and then through your PICC (IV line) and you were
started on blood thinning agents.
You are being discharged on intravenous antibiotics for at least
4 weeks and will follow-up with Infectious Disease in the next
1-2 weeks to determine the course.
You will need to continue with the coumadin and have your INR
(coumadin level) checked on Tuesday, [**7-20**] to ensure that the
level is in the right range. Please do this at your PCP's
office. We suspect that you will need the coumadin for at least
several months, and will discuss with the neurologists and your
PCP regarding the exact length of time.
The infusion company that will be helping you take the
antibiotics at home, will also be taking blood work from you to
send to the infectious disease clinic about your medications.
We also suggest that you talk to Dr [**Last Name (STitle) **] about getting help
with social support for your anxiety, as this may help you cope
even better with the medical problems that you are having.
New medications:
1. Vancomycin 2gm intravenous every 12 hours
2. Ceftriaxone 2gm intravenous every 12 hours
3. Metronidazole (flagyl) 500mg by mouth every 8 hours
4. warfarin (coumadin) - to be dosed per oyur PCP. [**Name10 (NameIs) **] should
NOT take any of this medication when you first get home, and
your doctor will tell you how to adjust this medication after
that. We will give you a prescription for the warfarin for now.
5. Afrin nasal spray. You should only need this for another 2
days, and then need to stop taking this.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 10827**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: [**Last Name (LF) **], [**2151-7-19**]:30AM
Location: [**Doctor Last Name **] & [**Doctor Last Name 3880**] LLC
Address: [**Location (un) 3881**], [**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 2349**]
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30447**],MD
Department: Internal Medicine
When: [**Last Name (LF) **], [**7-20**] (please call when you are ready to go in
tomorrow morning and they will find you a time to see the nurse
practicioner for the bloodwork and will tell you when you will
see Dr [**Last Name (STitle) **] next week.)
Location: [**Hospital1 **] FAMILY MEDICINE
Address: [**Apartment Address(1) 30444**], [**Hospital1 **],[**Numeric Identifier 14243**]
Phone: [**Telephone/Fax (1) 30445**]
** Dr. [**Last Name (STitle) 30448**] office asks that you please obtain a referral from
your pcp for your appointment with Dr. [**First Name (STitle) **] on [**8-16**] **
Department: NEUROLOGY
When: [**Month (only) **] [**2151-8-16**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2151-7-28**] at 9:30 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
Department: INFECTIOUS DISEASE
When: THURSDAY [**2151-8-26**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"285.29",
"461.2",
"300.00",
"461.0",
"461.3",
"378.51",
"378.54",
"599.0",
"437.6",
"041.4",
"470"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"22.63",
"22.2",
"22.52",
"21.88"
] |
icd9pcs
|
[
[
[]
]
] |
8680, 8755
|
4760, 7444
|
324, 359
|
8836, 8836
|
3046, 4737
|
10774, 12837
|
2240, 2276
|
7499, 8657
|
8776, 8815
|
7470, 7476
|
8987, 10751
|
2291, 3027
|
2014, 2075
|
276, 286
|
387, 1995
|
8851, 8963
|
2097, 2103
|
2119, 2224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,872
| 160,602
|
53436+53437
|
Discharge summary
|
report+report
|
Admission Date: [**2136-10-25**] Discharge Date: [**2136-11-6**]
Date of Birth: [**2085-9-12**] Sex: F
Service: [**Location (un) 259**]/MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
female with a history of HIV/AIDS, end stage renal disease on
hemodialysis and cardiomyopathy, who was admitted with a
complaint of one month of coughing and shortness of breath.
Her cough is productive of a clear to yellowish sputum, and
she has had increasing weakness over the past two weeks. The
patient denies any fever, chills or weight loss. She does
complain of some night sweats.
In the Emergency Department, the patient had an oxygen
saturation of 88% in room air. She also complained of
abdominal pain which is similar to what she has had in the
past. Previous workup for abdominal pain has been extensive
and unrevealing to date.
PAST MEDICAL HISTORY:
1. HIV/AIDS, most recent CD4 count in [**8-13**], was 126. Viral
load in [**8-13**], was less than 50.
2. End stage renal disease secondary to HIV nephropathy, on
hemodialysis since [**2129**].
3. Hypertension.
4. Cardiomyopathy with ejection fraction of 30%.
5. Pulmonary hypertension.
6. Hyperparathyroidism.
7. Anemia.
8. G-6-PD deficiency.
9. Splenic hematoma.
ALLERGIES: Ciprofloxacin and Benadryl.
MEDICATIONS ON ADMISSION:
1. Lamivudine 50 mg p.o. once daily.
2. Didanosine 100 mg p.o. once daily.
3. Tenofovir 300 mg p.o. once daily.
4. Zidovudine 100 mg p.o. twice a day.
5. Bactrim double strength one tablet p.o. q.Monday,
Wednesday and Friday after dialysis.
6. Digoxin 0.125 mg q.Monday, Wednesday and Friday after
dialysis.
7. Neurontin 400 mg p.o. q.Monday, Wednesday and Friday
after dialysis.
8. Acyclovir 200 mg p.o. q12hours plus one extra after
dialysis.
9. Nephrocaps one capsule p.o. once daily.
10. Renagel 2400 mg p.o. three times a day.
11. Captopril 50 mg p.o. three times a day.
12. Metoprolol 100 mg p.o. twice a day.
13. Nystatin oral suspension 5 ccs p.o. four times a day.
14. Prevacid 30 mg p.o. once daily.
15. Doxepin 25 mg p.o. q.h.s.
16. Hydroxyzine 50 mg p.o. once daily.
PHYSICAL EXAMINATION: On admission, the patient was afebrile
with heart rate in the 80s, blood pressure 130/80, oxygen
saturation 87% in room air, up to 96% on two liters via nasal
cannula. A pulseless level of 6 mmHg was measured. In
general, the patient was comfortable and in no apparent
distress. The oropharynx was clear with moist mucous
membranes and no lesions. Pulmonary examination revealed
lungs with crackles at the right base. Cardiac examination
revealed a regular rate and rhythm, with a III/VI systolic
murmur at the apex. Abdominal examination showed mild left
lower quadrant tenderness which was not reproducible.
Abdomen was soft. Extremities had no cyanosis, clubbing or
edema.
LABORATORY DATA: Initial laboratory studies were significant
for a white blood cell count of 4.3, hematocrit 33.0,
platelet count of 212,000. The MCV was 72. Panel seven
revealed a blood urea nitrogen of 24, creatinine 5.0.
Chest x-ray showed cardiomegaly with right lower lobe
consolidation and a right sided pleural effusion consistent
with congestive heart failure.
Electrocardiogram showed normal sinus rhythm at 88 beats per
minute, normal axis and intervals, inferolateral T wave
inversions which were new compared to electrocardiogram in
[**2134-11-12**].
A chest CT showed massive cardiomegaly with a pericardial
effusion. Enlarged pulmonary artery was consistent with
pulmonary artery hypertension. Bilateral pleural effusions
were noted. Two 4.0 to 5.0 millimeter nodules were noted at
the right lung apex which were old compared to prior
examinations. A subcapsular calcification of the spleen was
suggestive of a prior hematoma.
Transthoracic echocardiogram reconfirmed the pericardial
effusion but did not display any evidence of tamponade. Of
note, the patient had moderate left ventricular hypertrophy
with moderate global hypokinesis.
HOSPITAL COURSE:
1. Cardiovascular - The patient's shortness of breath was
attributed to congestive heart failure. More fluid was
removed during the patient's subsequent dialysis treatments,
and serial chest x-rays revealed improvement in the
congestive heart failure and decrease in the size of the
right pleural effusion. The decision was made that it was
not necessary to tap the pericardial effusion. Repeat
transthoracic echocardiography on [**2136-11-1**], showed the
presence of a trivial pericardial effusion, much smaller than
before, with mild symmetric left ventricular hypertrophy, and
moderate global hypokinesis. An ejection fraction was
estimated at 40% at this time. The patient's symptoms of
shortness of breath had essentially resolved at this point of
her hospitalization. The patient's cardiac enzymes were
measured on [**2136-10-26**], with a CK of 43 and a troponin I of
7.7. On [**2136-10-29**], the patient's troponin was noted to be
13.5. Troponin levels trended downward from here to 6.7 on
[**2136-10-30**], and 5.7 on [**2136-11-3**]. CK levels remained normal
throughout. Repeat electrocardiograms showed persistent T
wave inversions in the inferolateral leads. A Persantine
MIBI was performed on [**2136-11-6**]. The patient experienced no
pain or discomfort and no ST changes were observed. Nuclear
images showed no defects during stress or at rest with no
wall motion abnormalities and an estimated ejection fraction
of 45%. The etiology of the elevated troponin was thought to
be secondary to pulmonary hypertension and/or congestive
heart failure, with the possibility of a myocarditis or
pericarditis. It is not believed that the patient has any
coronary artery disease.
2. Infectious disease - The patient was continued on her
HAART therapy. She remained afebrile throughout her
hospitalization and did not require any antibiotics for
treatment. An expectorated sputum showed only oropharyngeal
flora. Blood cultures drawn on [**2136-10-29**], were negative.
Clostridium difficile test was negative on [**2136-11-5**]. A PPD
with anergy panel was planted and all were negative during
her hospitalization (the patient was anergic). The patient;s
effusions were thought to be secondary to congestive heart
failure and not tuberculosis given the resolution with
increased fluid removal with dialysis.
3. Renal - The patient was continued on her regular
hemodialysis schedule.
4. Endocrine - On [**2136-10-28**], the patient was found on the
floor of her room. She did not complain of any
light-headedness or diaphoresis. A blood sugar at the time
was noted to be 10, and the patient was administered ampules
of dextrose 50, started on a dextrose 10 drip, and treated
with glucagon as well as Dexamethasone. Her blood sugar
remained depressed and required continued boluses of dextrose
50 with Dexamethasone to maintain normal blood sugar. A
measured insulin level on [**2136-10-28**], was 18 (slightly above
normal), and repeat insulin levels on [**2136-10-29**], and [**2136-10-30**],
were 44 and 41, respectively. A measured C-peptide level on
[**2136-10-28**], was 5.5 (normal is 0.6-3.2). Pro insulin and ACTH
levels were pending at the time of discharge.
The patient was transferred to the Medical Intensive Care
Unit on [**2136-10-29**], for close blood sugar monitoring. Her
blood sugar remained stable in the 100 to 200 range while she
was maintained on a dextrose 10 drip and Dexamethasone. She
was returned to the floor on [**2136-10-30**], and her blood sugar
remained in the normal range thereafter. All further
supplementation with steroids as well as dextrose infusions
was discontinued and the patient did not have further
abnormal hypoglycemic episodes. It is believed that the
patient was inadvertently administered an oral hypoglycemic
[**Doctor Last Name 360**], which caused the hypoglycemic episode on [**2136-10-28**].
5. Pulmonary - The patient's cough persisted, though
decreased in intensity during her hospitalization. The ace
inhibitor should be considered as a possible etiology of the
patient's cough. Consideration should be made to change to
an angiotensin receptor blocking [**Doctor Last Name 360**].
6. Gastrointestinal - The patient was continued on her
proton pump inhibitor. Of note, the patient's liver function
tests were elevated on [**2136-10-29**], with an ALT of 41, AST 122,
alkaline phosphatase 234, total bilirubin 2.6. A right upper
quadrant ultrasound performed on [**2136-10-30**], showed an
echogenic liver with patent portal vein flow. No obstruction
was noted. Serial measurements of liver function tests
showed a return to normal levels. The etiology of this rise
is uncertain, but may be related to the patient's
hypoglycemic episode.
7. Dermatology - The patient complained of persistent
pruritus which has been a chronic problem for greater than
three years. The etiology of her pruritus is thought to be
secondary to her end stage renal disease. She was treated
with Doxepin, Hydroxyzine, and Sarna Lotion. A dermatology
consultation recommended starting Lac-Hydrin cream for the
patient's legs, Eucerin cream for general moisturizing, and
Nizoral cream for tinea versicolor on the patient's neck.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition to home with visiting nurse services.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. HIV/AIDS.
3. End stage renal disease on hemodialysis.
4. Hypertension.
5. Cardiomyopathy.
6. Pulmonary hypertension.
7. Anemia.
8. G-6-PD deficiency.
9. Hyperparathyroidism.
10. Splenic hematoma.
MEDICATIONS ON DISCHARGE:
1. Lamivudine 50 mg p.o. once daily.
2. Didanosine 100 mg p.o. once daily.
3. Tenofovir 300 mg p.o. once daily.
4. Zidovudine 100 mg p.o. twice a day.
5. Bactrim double strength one tablet p.o. q.Monday,
Wednesday and Friday after dialysis.
6. Digoxin 0.125 mg q.Monday, Wednesday and Friday after
dialysis.
7. Neurontin 300 mg p.o. q.Monday, Wednesday and Friday
after dialysis.
8. Acyclovir 200 mg p.o. q12hours plus one extra after
dialysis.
9. Nephrocaps one capsule p.o. once daily.
10. Renagel 2400 mg p.o. three times a day.
11. Captopril 50 mg p.o. three times a day.
12. Metoprolol 100 mg p.o. twice a day.
13. Nystatin oral suspension 5 ccs p.o. four times a day.
14. Prevacid 30 mg p.o. once daily.
15. Doxepin 25 mg p.o. q.h.s.
16. Hydroxyzine 50 mg p.o. once daily.
17. Sarna Lotion topically four times a day p.r.n.
18. Eucerin cream topically apply to dry skin twice a day.
19. Lac-Hydrin cream topically to legs twice a day.
20. Nizoral cream topically twice a day to neck times
fourteen days.
FOLLOW-UP PLANS:
1. Start new medications as instructed.
2. Contact primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7626**], for a
follow-up visit in one to two weeks.
3. Call infectious disease physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4427**], for a
follow-up appointment in two weeks.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 6916**]
MEDQUIST36
D: [**2136-11-7**] 11:22
T: [**2136-11-11**] 10:28
JOB#:
Admission Date: [**2136-10-25**] Discharge Date: [**2136-11-6**]
Date of Birth: [**2085-9-12**] Sex: F
Service: [**Location (un) 259**]/MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
female with a history of HIV/AIDS, end stage renal disease on
hemodialysis and cardiomyopathy, who was admitted with a
complaint of one month of coughing and shortness of breath.
Her cough is productive of a clear to yellowish sputum, and
she has had increasing weakness over the past two weeks. The
patient denies any fever, chills or weight loss. She does
complain of some night sweats.
In the Emergency Department, the patient had an oxygen
saturation of 88% in room air. She also complained of
abdominal pain which is similar to what she has had in the
past. Previous workup for abdominal pain has been extensive
and unrevealing to date.
PAST MEDICAL HISTORY:
1. HIV/AIDS, most recent CD4 count in [**8-13**], was 126. Viral
load in [**8-13**], was less than 50.
2. End stage renal disease secondary to HIV nephropathy, on
hemodialysis since [**2129**].
3. Hypertension.
4. Cardiomyopathy with ejection fraction of 30%.
5. Pulmonary hypertension.
6. Hyperparathyroidism.
7. Anemia.
8. G-6-PD deficiency.
9. Splenic hematoma.
ALLERGIES: Ciprofloxacin and Benadryl.
MEDICATIONS ON ADMISSION:
1. Lamivudine 50 mg p.o. once daily.
2. Didanosine 100 mg p.o. once daily.
3. Tenofovir 300 mg p.o. once daily.
4. Zidovudine 100 mg p.o. twice a day.
5. Bactrim double strength one tablet p.o. q.Monday,
Wednesday and Friday after dialysis.
6. Digoxin 0.125 mg q.Monday, Wednesday and Friday after
dialysis.
7. Neurontin 400 mg p.o. q.Monday, Wednesday and Friday
after dialysis.
8. Acyclovir 200 mg p.o. q12hours plus one extra after
dialysis.
9. Nephrocaps one capsule p.o. once daily.
10. Renagel 2400 mg p.o. three times a day.
11. Captopril 50 mg p.o. three times a day.
12. Metoprolol 100 mg p.o. twice a day.
13. Nystatin oral suspension 5 ccs p.o. four times a day.
14. Prevacid 30 mg p.o. once daily.
15. Doxepin 25 mg p.o. q.h.s.
16. Hydroxyzine 50 mg p.o. once daily.
PHYSICAL EXAMINATION: On admission, the patient was afebrile
with heart rate in the 80s, blood pressure 130/80, oxygen
saturation 87% in room air, up to 96% on two liters via nasal
cannula. A pulseless level of 6 mmHg was measured. In
general, the patient was comfortable and in no apparent
distress. The oropharynx was clear with moist mucous
membranes and no lesions. Pulmonary examination revealed
lungs with crackles at the right base. Cardiac examination
revealed a regular rate and rhythm, with a III/VI systolic
murmur at the apex. Abdominal examination showed mild left
lower quadrant tenderness which was not reproducible.
Abdomen was soft. Extremities had no cyanosis, clubbing or
edema.
LABORATORY DATA: Initial laboratory studies were significant
for a white blood cell count of 4.3, hematocrit 33.0,
platelet count of 212,000. The MCV was 72. Panel seven
revealed a blood urea nitrogen of 24, creatinine 5.0.
Chest x-ray showed cardiomegaly with right lower lobe
consolidation and a right sided pleural effusion consistent
with congestive heart failure.
Electrocardiogram showed normal sinus rhythm at 88 beats per
minute, normal axis and intervals, inferolateral T wave
inversions which were new compared to electrocardiogram in
[**2134-11-12**].
A chest CT showed massive cardiomegaly with a pericardial
effusion. Enlarged pulmonary artery was consistent with
pulmonary artery hypertension. Bilateral pleural effusions
were noted. Two 4.0 to 5.0 millimeter nodules were noted at
the right lung apex which were old compared to prior
examinations. A subcapsular calcification of the spleen was
suggestive of a prior hematoma.
Transthoracic echocardiogram reconfirmed the pericardial
effusion but did not display any evidence of tamponade. Of
note, the patient had moderate left ventricular hypertrophy
with moderate global hypokinesis.
HOSPITAL COURSE:
1. Cardiovascular - The patient's shortness of breath was
attributed to congestive heart failure. More fluid was
removed during the patient's subsequent dialysis treatments,
and serial chest x-rays revealed improvement in the
congestive heart failure and decrease in the size of the
right pleural effusion. The decision was made that it was
not necessary to tap the pericardial effusion. Repeat
transthoracic echocardiography on [**2136-11-1**], showed the
presence of a trivial pericardial effusion, much smaller than
before, with mild symmetric left ventricular hypertrophy, and
moderate global hypokinesis. An ejection fraction was
estimated at 40% at this time. The patient's symptoms of
shortness of breath had essentially resolved at this point of
her hospitalization. The patient's cardiac enzymes were
measured on [**2136-10-26**], with a CK of 43 and a troponin I of
7.7. On [**2136-10-29**], the patient's troponin was noted to be
13.5. Troponin levels trended downward from here to 6.7 on
[**2136-10-30**], and 5.7 on [**2136-11-3**]. CK levels remained normal
throughout. Repeat electrocardiograms showed persistent T
wave inversions in the inferolateral leads. A Persantine
MIBI was performed on [**2136-11-6**]. The patient experienced no
pain or discomfort and no ST changes were observed. Nuclear
images showed no defects during stress or at rest with no
wall motion abnormalities and an estimated ejection fraction
of 45%. The etiology of the elevated troponin was thought to
be secondary to pulmonary hypertension and/or congestive
heart failure, with the possibility of a myocarditis or
pericarditis. It is not believed that the patient has any
coronary artery disease.
2. Infectious disease - The patient was continued on her
HAART therapy. She remained afebrile throughout her
hospitalization and did not require any antibiotics for
treatment. An expectorated sputum showed only oropharyngeal
flora. Blood cultures drawn on [**2136-10-29**], were negative.
Clostridium difficile test was negative on [**2136-11-5**]. A PPD
with anergy panel was planted and all were negative during
her hospitalization (the patient was anergic). The patient;s
effusions were thought to be secondary to congestive heart
failure and not tuberculosis given the resolution with
increased fluid removal with dialysis.
3. Renal - The patient was continued on her regular
hemodialysis schedule.
4. Endocrine - On [**2136-10-28**], the patient was found on the
floor of her room. She did not complain of any
light-headedness or diaphoresis. A blood sugar at the time
was noted to be 10, and the patient was administered ampules
of dextrose 50, started on a dextrose 10 drip, and treated
with glucagon as well as Dexamethasone. Her blood sugar
remained depressed and required continued boluses of dextrose
50 with Dexamethasone to maintain normal blood sugar. A
measured insulin level on [**2136-10-28**], was 18 (slightly above
normal), and repeat insulin levels on [**2136-10-29**], and [**2136-10-30**],
were 44 and 41, respectively. A measured C-peptide level on
[**2136-10-28**], was 5.5 (normal is 0.6-3.2). Pro insulin and ACTH
levels were pending at the time of discharge.
The patient was transferred to the Medical Intensive Care
Unit on [**2136-10-29**], for close blood sugar monitoring. Her
blood sugar remained stable in the 100 to 200 range while she
was maintained on a dextrose 10 drip and Dexamethasone. She
was returned to the floor on [**2136-10-30**], and her blood sugar
remained in the normal range thereafter. All further
supplementation with steroids as well as dextrose infusions
was discontinued and the patient did not have further
abnormal hypoglycemic episodes. It is believed that the
patient was inadvertently administered an oral hypoglycemic
[**Doctor Last Name 360**], which caused the hypoglycemic episode on [**2136-10-28**].
5. Pulmonary - The patient's cough persisted, though
decreased in intensity during her hospitalization. The ace
inhibitor should be considered as a possible etiology of the
patient's cough. Consideration should be made to change to
an angiotensin receptor blocking [**Doctor Last Name 360**].
6. Gastrointestinal - The patient was continued on her
proton pump inhibitor. Of note, the patient's liver function
tests were elevated on [**2136-10-29**], with an ALT of 41, AST 122,
alkaline phosphatase 234, total bilirubin 2.6. A right upper
quadrant ultrasound performed on [**2136-10-30**], showed an
echogenic liver with patent portal vein flow. No obstruction
was noted. Serial measurements of liver function tests
showed a return to normal levels. The etiology of this rise
is uncertain, but may be related to the patient's
hypoglycemic episode.
7. Dermatology - The patient complained of persistent
pruritus which has been a chronic problem for greater than
three years. The etiology of her pruritus is thought to be
secondary to her end stage renal disease. She was treated
with Doxepin, Hydroxyzine, and Sarna Lotion. A dermatology
consultation recommended starting Lac-Hydrin cream for the
patient's legs, Eucerin cream for general moisturizing, and
Nizoral cream for tinea versicolor on the patient's neck.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition to home with visiting nurse services.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. HIV/AIDS.
3. End stage renal disease on hemodialysis.
4. Hypertension.
5. Cardiomyopathy.
6. Pulmonary hypertension.
7. Anemia.
8. G-6-PD deficiency.
9. Hyperparathyroidism.
10. Splenic hematoma.
MEDICATIONS ON DISCHARGE:
1. Lamivudine 50 mg p.o. once daily.
2. Didanosine 100 mg p.o. once daily.
3. Tenofovir 300 mg p.o. once daily.
4. Zidovudine 100 mg p.o. twice a day.
5. Bactrim double strength one tablet p.o. q.Monday,
Wednesday and Friday after dialysis.
6. Digoxin 0.125 mg q.Monday, Wednesday and Friday after
dialysis.
7. Neurontin 300 mg p.o. q.Monday, Wednesday and Friday
after dialysis.
8. Acyclovir 200 mg p.o. q12hours plus one extra after
dialysis.
9. Nephrocaps one capsule p.o. once daily.
10. Renagel 2400 mg p.o. three times a day.
11. Captopril 50 mg p.o. three times a day.
12. Metoprolol 100 mg p.o. twice a day.
13. Nystatin oral suspension 5 ccs p.o. four times a day.
14. Prevacid 30 mg p.o. once daily.
15. Doxepin 25 mg p.o. q.h.s.
16. Hydroxyzine 50 mg p.o. once daily.
17. Sarna Lotion topically four times a day p.r.n.
18. Eucerin cream topically apply to dry skin twice a day.
19. Lac-Hydrin cream topically to legs twice a day.
20. Nizoral cream topically twice a day to neck times
fourteen days.
FOLLOW-UP PLANS:
1. Start new medications as instructed.
2. Contact primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7626**], for a
follow-up visit in one to two weeks.
3. Call infectious disease physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4427**], for a
follow-up appointment in two weeks.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 6916**]
MEDQUIST36
D: [**2136-11-7**] 11:22
T: [**2136-11-11**] 10:28
JOB#:[**Job Number 3775**]
|
[
"425.4",
"251.2",
"282.2",
"252.0",
"416.0",
"423.9",
"403.91",
"042",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20645, 20883
|
20909, 21929
|
12614, 13403
|
15288, 20513
|
13426, 15271
|
21946, 22584
|
11473, 12150
|
12172, 12588
|
20538, 20624
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,824
| 124,830
|
16669
|
Discharge summary
|
report
|
Admission Date: [**2162-11-28**] Discharge Date: [**2162-12-13**]
Date of Birth: [**2087-3-15**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with a history of partial gastrectomy, transferred from
[**Hospital3 3583**] after having been found to be in hepatic
failure. The patient was also found to have an elevated
Tylenol level. The family reports that a neighbor found her
on the floor of her living room on the day prior to
presentation at the outside hospital. She was brought to the
Emergency Department, and she states that she fell on the
morning of presentation but was unable to contact help. She
denied loss of consciousness, head trauma, fevers, chills,
chest pain, shortness of breath, and palpitations. Last
contact with her family was [**Name (NI) 2974**] evening prior to
presentation.
At [**Hospital3 3583**], the initial laboratory values revealed an
ALT of 2662, an AST of 3613, an acetaminophen level greater
than 200. The lactate dehydrogenase was 12,397. Her
bicarbonate level was 9, and a blood gas revealed a pH of
7.22, CO2 of 19.5, oxygen saturation of 127, glucose 41. Her
bilirubin at that time was 0.8, her INR was 1.6. The patient
said that she had felt a little disoriented. She was given
two ampules of sodium bicarbonate, one ampule of dextrose 50,
and 25 grams of activated charcoal, and 140 mg/kg of
____________________. She was also given one dose of
Timentin as well. A head CT, chest x-ray and an abdominal
ultrasound were performed and reported to be normal. The
patient denied having taken many Tylenol tablets, however,
detailed pill count with her family revealed that
approximately 60 325 mg acetaminophen tablets were missing.
The patient states that she takes Lactaid (lactase
supplements) every day, two tablets twice daily, which are a
similar size and color to her acetaminophen tablets. The
patient's family also reports that she has periods of
confusion lasting 12 to 24 hours, that have resolved
spontaneously for the one to two months prior to
presentation. The patient and her family denied any other
exposures or injections (medications, mushrooms, chemicals or
illnesses).
The patient was transferred to [**Hospital1 188**] for fulminant hepatic failure.
PAST MEDICAL HISTORY:
1. Partial gastrectomy
2. Osteoporosis
3. Hypertension not being treated currently
4. Chronic pedal edema
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Halcion 0.5 mg in the evening
2. Lactaid two tablets by mouth three times a day
3. Tylenol as needed
4. Vioxx as needed
SOCIAL HISTORY: The patient quit smoking cigarettes 15 years
ago. She has a history of heavy alcohol consumption in the
past, but none for the past 13 years. She is a former
employee of the state lottery.
FAMILY HISTORY: Her mother died of an unknown cancer.
PHYSICAL EXAMINATION: On presentation, temperature 94.5,
heart rate 70, respiratory rate 20, blood pressure 142/61,
oxygen saturation 99% on room air. Generally, the patient
was comfortable, mildly confused, in no acute distress.
Head, eyes, ears, nose and throat: Pupils equal, round and
reactive to light and accommodation, extraocular movements
intact, anicteric sclerae, moist oropharynx, no jaundice
under tongue, no tongue fasciculations. Neck: Supple, no
lymphadenopathy, jugular venous pressure approximately 10 cm.
Heart: Regular, normal S1 and S2, II/VI systolic ejection
murmur at the left upper sternal border. Lungs: Clear to
auscultation bilaterally. Abdomen: Soft, normal active
bowel sounds, nontender, nondistended, palpable liver 4 to 5
cm below the costal margin in the midaxillary line, nontender
to palpation. The hepatojugular reflux was present.
Extremities: Trace pitting edema, +2 pedal edema, +2 pedal
pulses bilaterally. Skin: There were no spider angiomata,
palmar erythema, or dilated superficial veins. Neurologic
examination: Alert and oriented x 2, cranial nerves were
grossly intact. The patient was tangential. Light touch was
intact.
LABORATORY DATA: From the outside hospital showed Tylenol
greater than 200 as reported. The other laboratories as
reported above. The patient's chemistry panel revealed a
sodium of 140, potassium 5, chloride 111, bicarbonate 9,
creatinine 43, BUN 2.1, glucose 41. In the [**Hospital1 346**], her laboratory evaluations are as
follows: White blood cell count 10.2, hematocrit 28.8,
platelets 368. INR 2.9, lipase 218, ALT 2736, AST 3210,
alkaline phosphatase 88, amylase 272, total bilirubin 0.4.
Sodium 145, potassium 4.3, chloride 110, bicarbonate 11, BUN
53, creatinine 2.0, glucose 231. The electrocardiogram at
the outside hospital showed normal sinus rhythm with a rate
of 66, normal axis and intervals. There was early R wave
progression and left atrial enlargement.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit, where _________________ was continued at
the dose described above, that is specifically, 140 mg/kg
over one hour, followed by continuous infusion of 17.5 mg/kg
intravenously to maintain her INR less than 2. The patient
was also given vitamin K by mouth and subcutaneously. She
underwent extensive workup in the Intensive Care Unit, where:
1. Echocardiogram revealed left atrial enlargement. The
left ventricular function was preserved, with an ejection
fraction of 55%.
2. She underwent CT of the head which showed subtle
ill-defined areas of low attenuation in the central portion
of the medulla.
3. CT of the abdomen showed haziness of the mesentery,
intra-abdominal fluid, subcutaneous edema, and bilateral
pleural effusions, suggesting fluid overload. There was no
evidence of intra-abdominal collections.
While the patient's liver function eventually returned to
baseline, she remained acidemic, and her renal function
worsened. In consultation with the Nephrology service, it
was deemed that the patient underwent acute tubular necrosis
secondary to her hepatic failure. She required several days
of sodium bicarbonate infusion, which resulted in mild fluid
overload, however, the patient's renal function eventually
returned to [**Location 213**]. There was a spontaneous diuresis of the
peripheral edema and large bilateral pleural effusions. Of
note, the acute tubular necrosis was marked by evidence of
uremia, that is, the patient was nauseous and itchy. Those
symptoms resolved upon discharge.
The patient was evaluated by the Psychiatric service, which
deemed the acetaminophen toxicity as an accident. It was not
a suicide attempt.
The patient was evaluated by Physical Therapy and
Occupational Therapy services. Home occupational therapy was
recommended, as well as visiting nurse to make sure that the
patient takes her medications as prescribed.
In addition to acute tubular necrosis, the patient was found
to have mild pancreatitis during her hospital stay. As
stated above for the acute tubular necrosis, the patient was
aggressively hydrated with slight volume overload which
resolved once her kidney function improved. She required
some morphine for pain control, however, the patient's
pancreatitis resolved upon discharge.
DISCHARGE DIAGNOSIS:
1. Acute hepatic failure from acetaminophen toxicity
2. Acute tubular necrosis secondary to hepatic failure
3. Partial gastrectomy
4. Osteoporosis
5. Hypertension not being treated currently
5. Chronic pedal edema
DISCHARGE MEDICATIONS:
1. Calcium carbonate 500 mg by mouth three times a day
2. Vitamin D 400 units daily
3. Pantoprazole 40 mg daily
4. Alendronate 70 mg every [**Location 2974**]
5. Potassium chloride 20 mEq daily; this medication shall be
discontinued pending the recheck of her chemistry panel on
[**2162-12-17**].
6. Morphine sulfate IR 15 mg every six hours as needed for
pain
7. Colace 100 mg by mouth twice a day
DISPOSITION: To home with occupational therapy and visiting
nurse
FOLLOW UP: The patient will be seen in the [**Company 191**] West Clinic
on [**2162-12-17**], for repeat of her potassium and
evaluation of her kidney function. The patient has been
slightly hypokalemic on the days prior to admission, and this
is likely due to her spontaneous aggressive diuresis. The
patient will initiate primary care ultimately with Dr. [**First Name (STitle) **]
at [**Company 191**] West.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (STitle) 33392**]
MEDQUIST36
D: [**2162-12-13**] 18:01
T: [**2162-12-14**] 00:41
JOB#: [**Job Number 47183**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,532
| 181,315
|
52600
|
Discharge summary
|
report
|
Admission Date: [**2117-11-18**] Discharge Date: [**2117-12-14**]
Date of Birth: [**2071-6-14**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 5973**]
Chief Complaint:
GI bleeding, diarrhea and hematochezia
Major Surgical or Invasive Procedure:
-Upper endoscopy (EGD) X 3
-Colonoscopy done on [**12-1**]
-6 units of blood transfused
History of Present Illness:
Mr. [**Known lastname 108539**] is a 46-year-old male with past medical history
significant for severe PVD, HTN, atrial fibrillation,
depression, osteoporosis, ESRD s/p two failed transplants ([**2101**],
[**2107**]) who continues to be hemodialysis dependent and on
immunosuppression. He presented on this admission on [**11-18**]
complaining of
excessive bruising over his extremities, hematochezia and a
notable Hct drop from 29 to 22 in the setting of recent
initiation of multiple anticoagulation agents for SFA stenting
to his lower extremity during an admission in late [**Month (only) **]
[**2116**]. He had been taking Warfarin, Plavix and aspirin at home.
On arrival to ED he had stable hemodynamics as his initial VS
were: T 99.3F, HR 91, BP 100/56, RR 15, SPO2 96%.
.
He had been recently admitted on [**2117-10-29**] to the vascular
service for cold foot and blackened 2nd and 3rd L toes with dry
gangrene, found to have arterial emboli but no evidence of clot
in the heart. He recieved a stent to the SFA and that was when
he was started on clopidogral and warfarin alongside his usual
home ASA. He then presented for pain control on [**11-13**] and soon
thereafter discharge he states he had been noticing easy
bruising "all over" his extremities and diarrhea which contained
some hematochezia. In addition to a Hct drop from 29 to 22 in
the ED, he was noted to have hyperkalemia with peaked T waves
on EKG and recieved insulin, glucose and kayexelate. He was
admitted to the ICU for additional monitoring.
He was seen by vascular and GI services. GI team performed upper
endoscopies in the ICU twice. EGD #1 still food, EGD #2 with
duodenal ulcer with clean base, no clot, no active bleeding. GI
also recommended CT abdomen/pelvis for possible RP bleed given
such a large Hct drop and these additional CTs did not reveal
any evidence of bleeding. In the ICU he was given a total of 6
Units PRBCs, 22->29 with first 4 units, drifted down to 25 and
got 2 more units and came up to 31-32. Reversed INR to 1.5 with
PO vitamin K. Once his Hct remained stable over 24 hours and it
was thought he was stable enough to be transferred to the floor.
.
ICU course was also notable for fevers to 101F on [**11-21**]. He has
CXR with bilateral pleural effusions and mild hypoxia. He was
started on Vanc/Zosyn for possible aspiration PNA. He soon
became afebrile and his breathing was stable and back to high
90s saturations on room air so he was transferred to the medical
floor.
.
On presentation to the floor patient reported burning pain in
his foot relieved with standing up on it. He was also still
having small amounts of diarrhea, no blood or melena. ROS
negative for chest pain, chills, palpitations, abdominal pain,
dysuria. At time of transfer to the general medical service from
the ICU his vitals signs were 98.1F, BP106/60, HR78, RR16, and
O2 Sat 97% RA.
Past Medical History:
-ESRD due to long history of membranous nephropathy dating back
to his late teens, s/p 2 failed renal transplants ( [**2101**] and
[**2107**]); now with worsening renal function and uremia --> followed
by Dr. [**Last Name (STitle) 1366**] and Dr. [**Last Name (STitle) **]
[**Name (STitle) 35113**]
-Osteoporosis
-Depression
-Atrial fibrillation
-Peripheral Vascular Disease
.
Social History:
He had been living with mother and independent enough to drive
himself to his own dialysis sessions as an outpatient prior to
this admission. Former smoker, quit about 9-10 months ago. Also
former ETOH use, but reports no alcohol consumption in many
years. Denies illicit drug use.
Family History:
Non-contributory. Denies any family history of kidney diseases.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 96.9 BP: 116/91 HR: 104 RR: 16 02 sat: 92% 2L
GENERAL: A/Ox3, conversant, anxious appearing
HEENT: No icterus
CARDIAC: Irregularly irregular, tachycardic
LUNG: CTAB
ABDOMEN: Soft, NT, Distended bladder, BS+
EXT: No edema, Dusky 2nd, 3rd, 4th toes tender to palpation
Pertinent Results:
ADMISSION LABS:
[**2117-11-18**] 05:38PM GLUCOSE-71 UREA N-87* CREAT-8.1* SODIUM-135
POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-20* ANION GAP-25*
[**2117-11-18**] 05:38PM CALCIUM-7.1* PHOSPHATE-8.4* MAGNESIUM-1.9
[**2117-11-18**] 05:38PM WBC-10.2 RBC-2.47* HGB-7.8* HCT-24.1* MCV-98
MCH-31.5 MCHC-32.3 RDW-17.6*, PLT COUNT-212
[**2117-11-18**] 12:05PM GLUCOSE-84 UREA N-86* CREAT-8.4*# SODIUM-137
POTASSIUM-5.9* CHLORIDE-93* TOTAL CO2-23 ANION GAP-27*
[**2117-11-18**] 12:05PM ALT(SGPT)-38 AST(SGOT)-146* LD(LDH)-392* ALK
PHOS-76 TOT BILI-0.3
[**2117-11-18**] 12:05PM LIPASE-14
[**2117-11-18**] 12:05PM WBC-14.3* RBC-2.32* HGB-7.3* HCT-22.8* MCV-98
MCH-31.3 MCHC-31.9 RDW-17.7*, PLTS 285
[**2117-11-18**] 12:05PM PT-24.1* PTT-37.6* INR(PT)-2.3*
.
[**11-22**] LABS (Status Post 6 Units PRBCs):
[**2117-11-22**] 04:36AM BLOOD WBC-7.9 RBC-3.59* Hgb-11.1* Hct-33.9*
MCV-94 MCH-30.8 MCHC-32.7 RDW-18.1* Plt Ct-132*
.
ADDITIONAL LABS AND STUDIES/IMAGING:
.
[**11-19**] TTE:
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed (LVEF= 50-55%). Right ventricular
chamber size and free wall motion are normal. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. There is a small pericardial effusion.
.
IMPRESSION: No PFO or ASD seen. Mild global biventricular
systolic dysfunction. Small circumferential pericardial
effusion.
.
Compared with the prior study (images reviewed) of [**2117-10-30**],
LVEF is slighty lower at a higher heart rate. There has been
reaccumulation of a small pericardial effusion. The other
findings are similar (today's study is focused).
.
[**11-20**] Bleeding Study:
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for 90 minutes were obtained. A left
lateral view of the pelvis was also obtained. Blood flow images
show normal flow. Dynamic blood pool images show no abnormal
focus to suggest GI bleed.
IMPRESSION: Negative for GI bleed
.
[**11-20**] CXR:
HISTORY: Hypoxia, evaluate for edema or aspiration. AP upright
view. Comparison with [**2117-11-14**]. There is hazy density at the lung
bases and the costophrenic sulci are blunted consistent with
development of small pleural effusions. The left hemidiaphragm
is indistinct and the left
basilar infiltrate cannot be excluded. The heart and mediastinal
structures are unchanged. The bony thorax is grossly intact.
IMPRESSION: Development of small pleural effusions on the right.
A lateral
view may be helpful for further evaluation.
.
[**11-20**] CT Abd/Pelvis:
1. There is no evidence of retroperitoneal bleeding.
2. Small amount of pelvic fluid, perihepatic and perisplenic
fluid which is of low attenuation, consistent with ascites.
Periportal edema and gallbladder wall edema that could relate to
hypoalbuminemia or rehydration. Findings are new as compared to
the previous examination.
3. Bilateral new moderate pleural effusions accompanied by
compressive
atelectases.
4. Air in the urinary bladder likely due to presence of Foley
catheter, and in collecting system of the transplanted kidney.
.
EGD:
A small size hiatal hernia was seen, displacing the Z-line to
46 cm from the incisors, with hiatal narrowing at 48 cm from the
incisors.
Mucosa: Thick exudates, erythema of mucosa throughout the
esophagus. There was oozing and erosions at GE junction and in
the cardia.
Stomach: Normal stomach.
Duodenum:
Mucosa: Mild erythema of the mucosa was noted in the proximal
bulb ajacent to the ulcer.
Excavated Lesions A single cratered non-bleeding 5 mm ulcer was
found in the proximal bulb .
Impression: Small hiatal hernia
Thick exudates, erythema of mucosa throughout the esophagus in
the esophagus
Ulcer in the proximal bulb
Mild erythema in the proximal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: continue iv ppi
please send H.pylori serology
please check for [**Female First Name (un) 564**] of the tongue, if possible, could also
have [**Female First Name (un) 564**] esophagitis, did not blush esophagus since pt on
Plavix.
.
[**12-5**] PLAIN R ANKLE XRAYS -
RIGHT ANKLE, THREE VIEWS: The technologist note indicates pain
and bruising
over right lateral malleolus.There is possible minimal soft
tissue swelling over the medial malleolus. No acute fracture or
dislocation is identified. The mortise is congruent on this
non-stress view. A small calcification adjacent to the lateral
mid foot on the AP view is well corticated and unlikely to
represent an acute fracture.There are dense vascular
calcifications, suggesting background vasculopathy and possible
diabetes.IMPRESSION: No acute fracture detected.
.
[**12-5**] LEFT LE DOPPLER:
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the left common
femoral,
superficial femoral, and popliteal veins were performed. There
is normal
compressibility, flow and augmentation. Calf veins are
visualized and
demonstrate no evidence of thrombus. There is soft tissue edema.
IMPRESSION:No evidence of DVT.
.
EKGs :
.
[**12-9**] EKG: rate 80s, sinus rhythm with baseline artifact.
Anteroseptal myocardial infarction.Compared to the previous
tracing of [**2117-11-30**] there is no diagnostic change
.
[**11-30**] EKG: rate 88, Sinus rhythm with first degree A-V block.
Prolonged Q-T interval. Poor R wave progression. Possible
anterior wall myocardial infarction. Compared to the previous
tracing the rate is slower, Q-T interval prolongation is new.
Lateral ST-T wave abnormalities are slightly less pronounced.
.
[**11-20**] EKG -rate 80, sinus rhythm. The P-R interval is prolonged.
The Q-T interval is prolonged. There is a late transition which
is probably normal. Compared to the previous tracing sinus
rhythm has replaced atrial fibrillation.
.
CARDIAC BIOMARKERS:
[**2117-11-30**] 05:20AM BLOOD CK-MB-3 cTropnT-0.19*
[**2117-11-29**] 03:45PM BLOOD CK-MB-2 cTropnT-0.20*
[**2117-11-29**] 10:40AM BLOOD CK-MB-8 cTropnT-0.20*
[**2117-11-30**] 05:20AM BLOOD CK(CPK)-328*
[**2117-11-29**] 03:45PM BLOOD CK(CPK)-388*
[**2117-11-29**] 10:40AM BLOOD CK(CPK)-405*
.
HEPATITIS STUDIES:
[**2117-12-7**] 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
.
MICROBIOLOGY:
.
[**11-20**] Blood Cultures x 2 - negative
[**11-25**] Blood cultures x 3 - negative
[**11-29**] Blood Cultures x 2 - negative
[**12-4**] Blood Cultures x 2 - negative
[**12-5**] Blood Cultures x 1 - NGTD
[**12-8**] Blood Cultures x 2 - NGTD
.
STOOL STUDIES:
[**12-7**] C.difficile stool -Positive*
[**12-5**] C.difficile stool -negative
[**11-25**] C.difficile stool -negative
[**11-23**] C.difficile stool -negative
[**11-19**] C.difficile stool -negative
.
URINE STUDIES:
[**2117-11-29**] 03:17PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2117-11-25**] 09:47PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2117-11-29**] 03:17PM URINE Blood-SM Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2117-11-25**] 09:47PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2117-11-20**] 06:03PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2117-11-29**] 03:17PM URINE RBC-[**5-19**]* WBC-[**2-11**] Bacteri-MOD Yeast-NONE
Epi-0-2
[**2117-11-25**] 09:47PM URINE RBC-21-50* WBC-[**5-19**]* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2117-11-20**] 06:03PM URINE RBC-21-50* WBC-[**5-19**]* Bacteri-FEW
Yeast-NONE Epi-0-2 TransE-[**2-11**]
.
LABORATORY DATA ON DISCHARGE:
[**2117-12-14**] 07:10AM BLOOD WBC-7.0 RBC-2.89* Hgb-8.3* Hct-26.2*
MCV-90 MCH-28.6 MCHC-31.6 RDW-17.1* Plt Ct-505*
[**2117-12-13**] 08:20AM BLOOD PT-14.1* PTT-33.1 INR(PT)-1.2*
[**2117-12-14**] 07:10AM BLOOD Glucose-95 UreaN-46* Creat-7.7* Na-139
K-4.3 Cl-90* HCO3-21* AnGap-32*
[**2117-12-14**] 07:10AM BLOOD Calcium-8.5 Phos-5.5* Mg-1.8
Brief Hospital Course:
This is a 46 year old Caucasian gentleman [**Male First Name (un) 4746**] with ESRD s/p
failed renal transplants times 2 (still on rapamycin and
prednisone), recent LE clot s/p stent to SFA and development of
GIB from likely duodenal ulcer with MICU admission on [**2117-11-18**]
after initiation of coumadin, plavix,and ASA. Now with stable
hct, found to have c. diff, and now with worsening necrotic
changes of lower extremities, likely secondary to severe
peripheral vascular disease and calciphylaxis.
.
GI Bleed: The patient was admitted for multiple episodes of
maroon stool and a drop in HCT from 29 to 22 range. Started on
PPI IV BID, ASA/plavix held initially and INR was reversed with
FFP and vitamin K. Initial EGD was a difficult study with no
source of bleeding identified but repeat EGD found a
non-bleeding clean based duodenal ulcer which was felt to be the
probable source. Initial HCT was 22 which improved to 29 with 4
units PRBCs. However, he continued to have maroon stools and HCT
trended down to 25.8. He received 2 more units and his HCT
stabilized in the low 30s. PPI IV BID was continued. A bleeding
scan and CT abdomen/pelvis with IV contrast were both negative
for any source of bleeding, including aorto-enteric fistula
review. His bleeding source may have been the ulcer vs. oozing
AVMs. Hcts remained stable over several days prior to discharge.
.
Atrial fibrillation: After the patient was volume resuscitated
with blood and FFP, he converted to atrial fibrillation with
RVR, initial rates to the 140s. He was started on IV amiodarone
intially due to borderline low SBPs. Spontaneously converted to
NSR 2 days later and was well rate controlled on his home dose
of metoprolol. Metoprolol was later decreased due to low blood
pressures after HD on the medical floor but despite lower dose
of beta blocker he continued to have good rate control. Coumadin
held given recent GI bleeding and after discussion with vascular
team it was decided that given his recent SFA stent he should
still continue with his combination of Plavix and ASA for now.
He will follow up with the vascular surgeon /Dr. [**Last Name (STitle) **] as an
outpatient soon after discharge for close follow-up and
continued management of his anticoagulation needs given possible
embolus to leg making CHADS2 score higher.
.
Hypoxia /Fevers: Patient was somewhat hypoxic after his initial
EGD. CXR showed bilateral pleural effusions vs. infiltrate. On
[**11-21**] he spiked a fever to 101F and he was then started on
Vanc/Zosyn for possible aspiration PNA vs. HAP. A repeat CXR
showed no evidence of PNA and he remained afebrile for several
days so the antibiotics were discontinued.
.
Lower extremity ischemia / necrosis : Given his 2nd/3rd/4th left
toes advancing PVD changes and recent stenting he was continued
on ASA/Plavix after initial bleeding stabilized. Also continued
on Pletal. Coumadin held. Vascular continued to follow as was
awaiting full demarcation before considering surgery. He was
placed in multi-podis boots for more comfort and support with
plans to follow up with vascular team within one week after
discharge for further management. The renal team was also
increasingly concerned that the rapid progression of his LE
vasculopathy may be secondary to uremic calcific arteriopathy
and calciphylaxis complications. Thus, a dermatology consult was
called for an additional opinion and dermatology agreed that
that was the likely cause of his LE skin changes versus other
dermatologic manifestations. He was started on additional
Cinacalcet and then he began therapy with IV sodium thiosulfate
on [**2117-12-10**] for calciphylaxis treatment with close monitoring. He
tolerated this medication well and will receive this medication
as an outpatient during HD sessions. Patient cleared for home by
PT, and was given crutches. Able to ambulate at the time of
discharge.
.
ESRD on HD: Per discussions with renal team and review of older
records, it is felt that his renal disease is secondary to his
membranous glomerulopathy that dates back to when he was in his
late teens. He has unfortunately failed two renal transplants,
in [**2101**] and later, in [**2107**]. He is followed closely by Dr. [**Last Name (STitle) 1366**]
and the renal ransplant department here who changed his
sirolimus and prednisone doses on this admission. He will
continue to follow up with them as an outpatient.
.
Urinary retention: Patient had had problems with urinary
retention in the past and had been on prazosin. He was told to
stop taking it although was unclear why. While hospitalized he
again had trouble with urination. He was started on prazosin. He
urinates only once per day on average given that he is fairly
oliguric with his ESRD. Team initially felt his retention may
have been from opioids but even with higher doses on medical
floor he continued to have resolution of his retention issues so
his transient retention may have been related to UTI vs.
prostate enlargement. Continued on his prazosin.
.
UTI: With urinary retention and foley catheter from MICU patient
felt to be at risk for UTI and urine was positive. He was
started on cipro for 7 day course for complicated UTI on
[**2117-11-26**] which he completed. Follow up urine studies were
improved and his urine retention also improved slowly.
.
Clostridium difficile: Although he had multiple stool studies
that were negative for C.difficile colitis during this admission
( [**11-19**], [**11-23**], [**11-25**], [**12-5**] - all negative) he then had a
positive C.difficile stool study on [**12-7**] which was re-checked
after a fever spike to 101F and acute increase in the severity
and frequency of his diarrhea that he had been having
intermittently for nearly his entire hospital course. He is high
risk given his multiple hospitalizations along with several
courses of antibiotics in recent weeks for PNA and UTI as
outlined above. He was started in Flagyl on [**12-8**] with plan for
at least 14 day course. Diarrhea has improved significantly and
he had no accompanying abdominal pain with his infection.
.
Medications on Admission:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
7. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
10. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
Hve you INR checked in the usual manner. Goal INR [**1-12**].
Disp:*90 Tablet(s)* Refills:*2*
16. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours: prn.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
10. Sirolimus 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
13. Prazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
Disp:*120 Capsule(s)* Refills:*2*
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*28 Tablet(s)* Refills:*2*
16. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*336 Tablet(s)* Refills:*0*
17. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
18. Sodium Thiosulfate 10 % Solution Sig: AS DIR Intravenous q
HD: As directed by renal team at Hemodialysis sessions. To be
given at HD.
Discharge Disposition:
Home
Discharge Diagnosis:
-Upper GI Bleeding / duodenal and gastric area ulcers
-Clostridium difficile colitis
-Uremic calcific arteriopathy / Calciphylaxis
-Peripheral Vascular Disease
-Candidal Esophagitis
-Urinary Tract Infection
-Aspiration Pneumonitis
-ESRD on hemodialysis
-Atrial Fibrillation
-Urinary Retention
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance with walker,
crutches, or cane
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**].
.
You were admitted to the hospital with bleeding from your
rectum. You received multiple blood transfusions in the
intensive care unit in order to stabilize your blood pressure.
You underwent several upper endoscopies and colonscopies to find
the source of bleeding and were found to have ulcers near your
stomach region. Your bleeding stabilized and your red blood cell
count remained stable with no signs of residual bleeding for the
rest of your hospital course. It was felt that the combination
of several blood thinning medications after your recent stent
placement may have predisposed you to this GI bleed so these
medications were held and then you were only restarted on 2 of
them (Plavix and Aspirin restarted but Coumadin was
discontinued).
.
You also had a fever while hospitalized. You were treated for a
possible pneumonia with antibiotics. After a few days your chest
x-ray did not show a pneumonia and these antibiotics were
discontinued. You were noted to have some evidence of esophageal
candidiasis which is a fungal infection in the throat/esophagus.
You were given 2 weeks of anti-fungal therapy and this condition
resolved. You had an additional urinary tract infection as well
which was treated with 1 week of antibiotics. Later in your
hospital course you had additional fevers and diarrhea which was
persistent. Stool studies revealed that you had an infection
called Clostridium difficile so you are being treated with
Flagyl for this condition. You should continue to take this
antibiotic as an outpatient through [**12-21**].
.
You were followed by the vascular team and the renal team while
you were in the hospital. A dermatology consult was also called
to evaluate your worsening skin lesions over your lower
extremities. Ultimately, the vascular, renal and dermatology
doctors [**Name5 (PTitle) **] agreed that your rapidly progressing peripheral
vascular disease and skin changes were from your peripheral
vascular disease as well as a condition seen in renal disease
called uremic calcific arteriopathy or calciphylaxis. Your renal
medications were adjusted and you were treated with a therapy
called sodium thiosulfate to try to hinder the progress of this
condition. You have been set up with Dr. [**Last Name (STitle) **] for close
outpatient follow-up. You will continue to receive treatments
with sodium thiosulfate at your dialysis unit and will have
close follow-up with Dr. [**Last Name (STitle) 1366**].
.
Medication Changes / Instructions:
-You should continue taking Flagyl with last day on [**12-21**]
-You will be given sodium thiosulfate during your dialysis
sessions
-You were started on prazosin 2mg twice a day
-Your Sirolimus was changed to 0.5mg daily
-Your Prednisone was changed to 5mg every other day
-Your Amlodipine was changed to 5mg every day
-Your Metoprolol was changed to 25mg twice a day
-Your Aspirin was changed to 81mg daily
-Your Coumadin was stopped due to recent GI bleed
-You were started on a renal medication called Cinacalcet
-Your oxycontin was increased to 40mg twice a day
-Your oxycodone was increased to 5-10mg every 4 hours
.
Please be advised that you should not mix these pain medications
with alcohol or other sedatives, and do not take these
medications if driving as they cause drowsiness.
.
If you experience and fevers, chills, bloody stool, worse lower
extremity pains, dizziness, confusion, fainting, more rapid
expansion of lower extremity rash/discoloration, worse diarrhea,
abdominal pains, burning with urination, urine retention, bloody
urine, or any other concerns please return to the emergency room
promptly.
Followup Instructions:
Please follow up with your vascular surgeon, Dr. [**Last Name (STitle) **], on
[**12-17**] at 9:30 am. Phone #[**Telephone/Fax (1) 1241**].
.
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
on [**2117-12-31**] at 10:40AM. Phone: [**Telephone/Fax (1) 250**].
.
Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on Tuesday [**12-21**] 3:40pm. If you need to reschedule this appointment please
call. Phone: [**Telephone/Fax (1) 673**].
|
[
"276.7",
"996.81",
"788.29",
"532.40",
"285.1",
"790.01",
"709.3",
"112.84",
"440.20",
"285.21",
"V45.11",
"733.00",
"440.4",
"553.3",
"585.6",
"507.0",
"531.40",
"008.45",
"403.91",
"599.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.95",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
22251, 22257
|
12592, 18681
|
314, 403
|
22594, 22594
|
4430, 4430
|
26478, 27009
|
4022, 4087
|
20337, 22228
|
22278, 22573
|
18707, 20314
|
22781, 26455
|
4127, 4411
|
12228, 12569
|
236, 276
|
431, 3306
|
4446, 12214
|
22609, 22757
|
3328, 3707
|
3723, 4006
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,349
| 130,749
|
47250
|
Discharge summary
|
report
|
Admission Date: [**2161-2-17**] Discharge Date: [**2161-2-25**]
Date of Birth: [**2111-3-20**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Shellfish
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
lightheadedness, abdominal pain
Major Surgical or Invasive Procedure:
Endoscopy with biopsy of gastric ulcer
octreotide nuclear scan
History of Present Illness:
49yoW with h/o peptic ulcers, Gerd, s/p gastric fundoplication
[**3-18**] presenting with lightheadedness and abdominal pain. She
was in her normal state of health until about two weeks ago when
she developed bilateral lower quadrant abdominal pain and
nausea, no vomiting, and melana. She was admitted to [**Hospital 7301**] and underwent EGD with cauterization of 3 gastric
ulcerations, and was discharged [**2161-2-14**] on a PPI. She presented
[**2161-2-17**] to the [**Hospital1 18**] ED with continued bilateral lower quadrant
abdominal pain and lightheadedness. She also noted dark stools
after discharge, but had not had a bowel movement for 2 days
prior to presentation. In the ED, Hct noted to be 12, and she
was transfused a unit PRBC. She was taken for emergent EGD,
which showed a 25mm gastric ulcer with heaped edges. No
interventions were taken. She was then admitted to the MICU for
further monitoring.
.
Additionally on presentation to the ED she was febrile to 103.2.
She defevesced by day two of admission, and no infectious
source has been found. CXR, UA, and blood cultures have been
nondiagnostic. She was treated with CTX and flagyl and the ED,
and continued on broad spectrum antibiotics with levofloxacin
and flagyl while in the MICU. She denied any history of fevers,
chills, sweats, cough, dysuria, skin rashes or ulcerations.
Past Medical History:
1. peptic ulcer disease
2. Gerd s/p Nissen fundoplication [**3-/2160**]
3. facial and abdominal burns [**2156**]
4. depression
Social History:
lives with her mother; does not work
Tob: 10yrs x 1ppd
EtOH: rare
Illicits: none
Family History:
mother- asthma
father- d. prostate ca
Physical Exam:
T on initial presentation 103.2
T 98.7 HR 69 RR 12 BP 96/48
Gen: lying in bed, shaking legs bilaterally which she states
reduces abdominal pain, NAD
HEENT: PERRL, anicteric, conjunctiva pink, OP clear with MMM
Neck: supple, no LAD, no JVP
CV: RRR, no mrg, nml s1s2
Resp: CTAB
Abd: +BS, soft, ttp diffusely, greatest in upper bilateral
quadrants, no rebouding, no guarding, also with burn scar on
abdomen
Ext: no edema, nontender, 2+DP pulses B
Neuro: A&Ox3, CN II-XII intact, motor and sensation intact
grossly
Pertinent Results:
[**2161-2-17**] CT: IMPRESSION: Status post Nissen fundoplication. No
evidence of free air or intra- abdominal abscess. Ulcer
identified by EGD not definitely seen on this CT study. Findings
discussed with the gastrointestinal team.
[**2161-2-17**] CXR: no acute cardiopulm disease
[**2161-2-24**] Octreotide scan: no octreotide uptake
[**2161-2-17**] 08:00AM PT-12.8 PTT-23.4 INR(PT)-1.0
[**2161-2-17**] 08:00AM PLT COUNT-321
[**2161-2-17**] 08:00AM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2161-2-17**] 08:00AM NEUTS-85.0* LYMPHS-13.3* MONOS-1.4* EOS-0.1
BASOS-0.2
[**2161-2-17**] 08:00AM WBC-14.9* RBC-1.37*# HGB-4.0*# HCT-12.6*#
MCV-92 MCH-29.2 MCHC-31.7 RDW-17.7*
[**2161-2-17**] 08:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-2-17**] 08:00AM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.5*
[**2161-2-17**] 08:00AM CK-MB-NotDone cTropnT-<0.01
[**2161-2-17**] 08:00AM LIPASE-21
[**2161-2-17**] 08:00AM ALT(SGPT)-19 AST(SGOT)-19 CK(CPK)-30 ALK
PHOS-56 AMYLASE-54 TOT BILI-0.1
[**2161-2-17**] 08:00AM GLUCOSE-175* UREA N-27* CREAT-0.5 SODIUM-135
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2161-2-17**] 08:17AM LACTATE-3.1*
[**2161-2-17**] 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2161-2-17**] 09:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2161-2-17**] 11:00AM HCT-15.4*
[**2161-2-17**] 01:00PM PT-13.1 PTT-25.6 INR(PT)-1.1
[**2161-2-17**] 01:00PM PLT COUNT-197
[**2161-2-17**] 01:00PM WBC-10.8 RBC-2.22*# HGB-6.6*# HCT-19.1*
MCV-86 MCH-29.9 MCHC-34.6 RDW-15.8*
[**2161-2-17**] 05:47PM HCT-33.2*#
[**2161-2-17**] 09:30PM PLT COUNT-161
[**2161-2-17**] 09:30PM WBC-10.3 RBC-4.10*# HGB-12.4# HCT-34.2*
MCV-83 MCH-30.3 MCHC-36.3* RDW-15.7*
Brief Hospital Course:
49yo woman with history of Gerd, PUD, s/p Nissen fundoplication
presenting with upper GI bleed. During this hospitalization,
the following problems were addressed:
1. Upper GI bleed: The patient presented with a hematocrit of
12. She was transfused PRBC to treat anemia of acute blood
loses. GI service performed an urgent EGD and repeated it the
following day. Three large gastric ulcers were seen. Biopsy of
the ulcer wall and the gastroesophageal junction showed no
evidence of malignancy. Records were obtained from [**Hospital 2586**] showing a gastrin level of >1300, findings
concerning for a gastrinoma/Zollinger-[**Doctor Last Name 9480**] syndrome. In the
setting of PPI use, gastrin level may be elevated, but per GI,
it should not be >800. A level >1000 is suggestive of
gastrinoma even while on PPI. However, repeat of the gastrin
level here at [**Hospital1 18**] was 734. Additionally, she had an
octreotide scan that showed no octreotide uptaking areas that
would be consistent with a gastrinoma. Ulcers may therefore be
severe PUD due to H.pylori or NSAID use. She will follow-up
with GI outpatient for further work-up. Surgery was also
consulted and recommended gastrectomy. This was deferred until
further diagnostic work-up and medical interventions could be
explored. She was treated with high dose PPI Protonic 80mg [**Hospital1 **],
and H2 blocker, Pepcid 40mg [**Hospital1 **]. Pain was controlled in house
with morphine prn and changed to oxycodone prn prior to
discharge. She had no subsequent episodes of GI bleeding after
day one, and Hct remained stable at 39-40.
2. Fever: Patient itinially presented to ED with fever of
103.2. She defervesced by day two. Work-up for an infectious
source including chest x-ray, urinalysis and blood cultures was
nondiagnostic. She was treated with levofloxacin and flagyl
initially, but this was stopped on day three as no infectious
source was found. It was thought this fever was due to the GI
bleed. She had no further fevers.
3. Hypotension: the patient was hypotensive on the floor with
SBP in the 80s-100s. She continued to mentate well. It was
thought the low BP might be due to her many antidepressant meds,
benzodiazepines, and pain meds. The Klonipin dose was reduced,
and the Zyprexa was discontinued. BP was stable. Mood and
anxiety level were also stable.
4. Dispo: she was discharged to home with plans to follow-up
with [**Hospital **] clinic and primary care clinic. She is a full code.
Medications on Admission:
Meds on Admission:
Fluoxetine 10mg daily
Clonazepan 0.5mg tid
Olanzapine 30mg qhs
Mirtazapine 4.5mg qhs
Protonix 40mg [**Hospital1 **]
Meds on Transfer:
Protonix 40mg iv bid
Flagyl 500mg tid
Levofloxacin 500mg daily
Tylenol prn
Oxycodone 5mg prn
Fluoxetine 10mg daily
Clonazepan 0.5mg tid
Olanzapine 30mg qhs
Mirtazapine 4.5mg qhs
Discharge Medications:
1. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
5. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO every twelve (12)
hours.
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
upper GI bleed
gastric ulcers
Secondary:
Depression
Gerd s/p nissen fundoplication
facial and abdominal burns
Discharge Condition:
stable
Discharge Instructions:
If you develop any further episodes of bloody or black stool, if
you feel dizzy or lightheaded, or if you develop fever >101.3,
worsening abdominal pain, or any other concerning symptom,
please call your primary care physician [**Name Initial (PRE) **]/or return to the
emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-3-12**] 2:00
-Primary care clinic
Provider: [**Name10 (NameIs) **] Where: [**Hospital6 29**] MEDICAL SPECIALTIES
Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2161-3-10**] 2:00 [**Hospital 100039**]
Clinic
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in General Surgery [**2161-3-20**] at 1:30pm. You will need to call Dr. [**Last Name (STitle) 15645**] office prior to
this appointment to update your contact and insurance
information. You can call [**Telephone/Fax (1) 46193**].
|
[
"311",
"E939.0",
"458.29",
"285.1",
"531.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8297, 8303
|
4516, 7018
|
311, 376
|
8467, 8475
|
2639, 4493
|
8810, 9545
|
2042, 2081
|
7400, 8274
|
8324, 8446
|
7044, 7049
|
8499, 8787
|
2096, 2620
|
240, 273
|
404, 1771
|
7063, 7180
|
1793, 1925
|
1941, 2026
|
7198, 7377
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,461
| 126,289
|
42895
|
Discharge summary
|
report
|
Admission Date: [**2132-11-18**] Discharge Date: [**2132-11-20**]
Date of Birth: [**2086-10-16**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
neck hematoma
Major Surgical or Invasive Procedure:
Incision and drainage of left paratracheal
hematoma.
Surgeon: [**Doctor Last Name 1837**]
Date: [**2132-11-18**]
History of Present Illness:
46yo female with worsening neck swelling, hoarsness of
voice, difficulty swallowing since left parathyroid FNA on [**11-14**]
for
hyperparathryoidism with ?adenoma. She denies difficulty
breathing or
shortness of breath. She was seen at [**Hospital6 33**] ED
the
previous evening and had a CT neck showing a likely central
compartment hematoma with tracheal deviation. She was
discharged
home, and then presented to the [**Hospital1 18**] ED in early AM with the
same symptoms.
Past Medical History:
chronic renal failure, hypothyroidism, hyperparathyroid
Social History:
NC
Family History:
NC
Physical Exam:
AVSS, 100% on RA
NAD
breathing comfortably, no stertor or stridor
voice raspy, not breathy, able to count to 10 in one breath
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 19109**]
Face: nontraumatic
B/l anterior NC wnl
OC/OP: no trismus. Normal healthy mucosa with no lesions
Neck: Somewhat firm fullness mostly on the left neck, minimal
tenderness, no fluctuance or induration. Full ROM.
FOE: left lateral hypopharyngeal wall fullness effacing the left
pyriform and with mucosa bulging over the false cord. Easily
able to pass the area of edema with scope and glottis fully
visible and patent with no glottic airway compromise.
Pertinent Results:
[**2132-11-18**] 11:05PM GLUCOSE-153* UREA N-36* CREAT-2.8*
SODIUM-146* POTASSIUM-5.7* CHLORIDE-119* TOTAL CO2-17* ANION
GAP-16
[**2132-11-18**] 11:05PM CALCIUM-8.0* PHOSPHATE-3.2 MAGNESIUM-1.7
[**2132-11-18**] 09:40PM freeCa-1.14
[**2132-11-19**] 11:52PM BLOOD WBC-11.8* RBC-3.18* Hgb-9.5* Hct-29.3*
MCV-92 MCH-29.8 MCHC-32.4 RDW-12.6 Plt Ct-302
[**2132-11-19**] 08:00AM BLOOD WBC-15.5*# RBC-3.40* Hgb-9.8* Hct-31.4*
MCV-92 MCH-28.9 MCHC-31.3 RDW-12.6 Plt Ct-294
[**2132-11-19**] 11:52PM BLOOD PTH-246*
[**2132-11-19**] 04:40AM BLOOD freeCa-1.22
[**2132-11-19**] 04:47PM BLOOD Glucose-167* UreaN-37* Creat-2.7* Na-145
K-4.5 Cl-116* HCO3-19* AnGap-15
Brief Hospital Course:
The patient was admitted to the Otolaryngology - Head and Neck
Surgery service in stable condition on [**2132-11-18**], s/p incision
and drainage of paratracheal hematoma. Please see dictated op
note for details. Hospital course described below by system.
She was observed in the SICU overnight and transferred to the
floor on [**2132-11-19**]
ENT: Incision remained clean, dry, and intact throughout the
hospital stay. Neck had minimal swelling and stable ecchymosis.
The drain was removed in the usual fashion after meeting
criteria. CN 7 was intact and symmetrical in all branches. Voice
strong.
Neuro: Pain was controlled with IV and then po pain meds
Cardio: Initial tachycardia immediately post-op resolved by
discharge with HR ~90.
Pulm: Nasally ntubated until POD1 to protect airway. Extubated
per protocol without issue on POD1. O2 per nasal cannula was
weaned.
GI: The patient tolerated advancement of diet with >400cc po
intake at time of discharge.
GU: Hx chronic renal disease. Initial post-op hyperkalemia
corrected in SICU with no symptoms or EKG changes. Stable
potassium on discharge similar to baseline. IV fluids were
stopped when PO intake was greater than 400mL.
Endo: Endocrine consult service followed. Calcium stable at 8.0
on discharge with PTH>200. Patient will continue home meds and
was instructed to follow-up with endocrinologist tomorrow.
Heme: DVT prophylaxis with Heparin 5000 Units SC q 8 hours.
ID: Antibiotics administered perioperatively and then continued
while drain was in. Had positive blood cultures drawn in ED and
+Ucx. Was continued on antibiotics as outpatient for completion
of 5 day course.
At time of discharge the patient??????s pain was well controlled, no
chest pain or shortness or breath, no nausea/vomiting,
tolerating full diet, good urine output, ambulating. The
patient was afebrile, vital signs stable, CN7/11/12 intact and
symmetric bilaterally, neck soft/flat, incision c/d/i with no
erythema. No numbness, tingling, negative Chvostek's sign.
Medications on Admission:
Lisinopril 10 mg daily
Synthroid 112 mcg daily
Calcitriol 0.25 mcg 1 tab daily
Depo-Provera 150 mg im every 3 months
Discharge Medications:
1. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO three
times a day for 3 days.
5. Lisinopril 10mg daily
6. Tylenol prn pain
Discharge Disposition:
Home
Discharge Diagnosis:
Neck hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Wound: Keep incision dry for 48hours after surgery or 24hours
after drain removal, whichever is later. After that you may get
the wound wet while showering. Do not take baths or swim for
~4weeks. Sutures or staples will be removed at your follow-up
appointment
Activity: No strenuous activity for 2 weeks. No heavy lifting
greater than a carton of milk for 2 weeks.
Pain: pain control with tylenol
Followup Instructions:
Follow-up with your surgeon Dr. [**Last Name (STitle) 1837**]. Call his office
for an appointment in [**11-25**] weeks. [**Telephone/Fax (1) 41**].
Follow up appointment with your endocrinologist, Dr. [**Last Name (STitle) 7852**].
Call his office for an appointment on Friday (tomorrow).
Follow-up appointment with your primary care doctor within 1
week. Issues to follow-up are urinary tract infection on
admission and follow-up of blood cultures.
|
[
"E879.8",
"V45.73",
"V10.52",
"252.00",
"585.4",
"V49.87",
"998.12",
"276.7",
"278.00",
"244.9",
"599.0",
"276.2",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.98",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
4986, 4992
|
2429, 4441
|
327, 441
|
5050, 5050
|
1748, 2406
|
5623, 6076
|
1068, 1072
|
4609, 4963
|
5013, 5029
|
4467, 4586
|
5201, 5600
|
1087, 1729
|
274, 289
|
469, 952
|
5065, 5177
|
974, 1032
|
1048, 1052
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,163
| 106,067
|
38294
|
Discharge summary
|
report
|
Admission Date: [**2186-12-4**] Discharge Date: [**2186-12-6**]
Date of Birth: [**2151-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Gastroparesis, Hematemesis
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
Mr. [**Known lastname 14782**] is a 35 year-old man with DMI (c/b retinopathy,
DKA, gastroparesis), ESRD on HD (MWF), HTN presenting with
vomiting. He presents with his usual onset of gastric burning
pain earlier today. Also with nausea and vomiting. He also
described that he also had small a amount of bright red blood in
his vomitus. Denies any bright red blood per rectum or melena.
No fevers or chills. Patient denies any lightheadedness,
palpitations, chest pain, or shortness of breath. Of note, this
presentation is quite similar to prior periods of gastroparesis.
.
In the ED, initial vs were 97.3 105 211/125 18 98% RA. Patient
was tachycardic, with no focal findings including benign
abdomen. Labs were notable for K 5.3, Cr 8.9, BUN 56, glucose
288 and an anion gap of 16. Pt was given 4L NS, 4 units i.v.
insulin was started on an insulin drip, Zofran and morphine.
Guiaic was negative and NG lavage identified blood clots and
coffegrounds that cleard with 100 cc fluid. GI was consulted in
the ED and advised IV PPI, NPO and possible EGD in AM to
evaluate possible [**Doctor First Name 329**] [**Doctor Last Name **] tear from retching. The patient
was then admitted to the MICU for further care. On transfer, VS
were 86 158/80 18 98%RA.
.
Upon arrival to the floor, the patient appears uncomfortable in
bed.
Complains of nausea and retching.
Past Medical History:
- Type I diabetes: since age 19, complicated by gastroparesis,
retinopathy (laser treatment), DKA, chronic kidney disease
- ESRD, on HD MWF, started [**9-3**]
- [**Doctor Last Name 9376**] syndrome
- Hypertension
- Asthma
- HLD
- chronic multifactorial anemia, on Epo, h/o pRBC transfusion x2
in [**2186-7-24**] related to renal failure
Social History:
Lives with his girlfriend and two children ages 14 and [**Location (un) 85328**]. Denies tobacco use, alcohol use, or illicit drug use.
Family History:
Father with CAD/MI, HLD, type II DM. Mother with thyroid cancer.
Physical Exam:
T 97.0, P: 97, BP: 188/111, RR: 15, 98% on RA
GENERAL - well-appearing in NAD, uncomfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes, unable to examine OP as pt nauseous
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - tregular rhythm, tachycardic, no MRG
ABDOMEN - NABS, soft, diffuse TTP, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, dialysis catheter in place, fistula
in left UE
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-27**] throughout, sensation grossly intact throughout
Pertinent Results:
Admission:
[**2186-12-4**] 05:56PM BLOOD WBC-7.7 RBC-3.59* Hgb-10.8* Hct-32.8*
MCV-91 MCH-30.2 MCHC-33.0 RDW-15.1 Plt Ct-208
[**2186-12-4**] 05:56PM BLOOD Neuts-84.8* Lymphs-12.3* Monos-1.4*
Eos-0.9 Baso-0.6
[**2186-12-4**] 05:56PM BLOOD PT-9.7 PTT-36.5 INR(PT)-0.9
[**2186-12-4**] 05:56PM BLOOD Glucose-288* UreaN-56* Creat-8.9*# Na-137
K-5.3* Cl-101 HCO3-20* AnGap-21*
[**2186-12-4**] 09:13PM BLOOD Glucose-157* UreaN-54* Creat-8.1* Na-141
K-4.5 Cl-112* HCO3-20* AnGap-14
[**2186-12-4**] 09:13PM BLOOD ALT-15 AST-17 TotBili-0.7
[**2186-12-4**] 05:56PM BLOOD Calcium-9.1 Phos-5.4* Mg-2.0
.
Discharge labs:
[**2186-12-6**] 06:05AM BLOOD WBC-5.1 RBC-2.89* Hgb-8.7* Hct-27.0*
MCV-93 MCH-30.0 MCHC-32.1 RDW-14.7 Plt Ct-163
[**2186-12-6**] 06:05AM BLOOD Glucose-102* UreaN-30* Creat-6.1*# Na-140
K-3.9 Cl-103 HCO3-29 AnGap-12
[**2186-12-6**] 06:05AM BLOOD Calcium-8.1* Phos-5.0* Mg-1.8
.
EGD results [**12-5**]:
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Recommendations: No source of bleeding was found. There was no
blood in stomach or duodenum.
He may have had a small MW tear that was already healed.
Would continue home dose of omeprazole.
Brief Hospital Course:
Patient is a 35 year old man with type I diabetes mellitus,
gastroparesis, end stage renal disease on hemodialysis and
hypertension admitted with nausea, vomiting and hematemesis who
was initially admitted to the MICU for close monitoring of
hematmesis.
ACTIVE ISSUES:
#. Hematemesis: His small volume hematemesis was likely caused
by retching in the setting of gastroparesis. His NG lavage
cleared with 100mL. The hematocrit drop observed between his
presentation hct of 32.8 and admission hct of 25.9 was likely
hemodilution secondary to 4L NS given in the ED. He was started
on a pantoprazole drip, antiemetics. Endoscopy showed no
evidence of bleeding, so small mucosal tear suspected as
etiology. Hematocrit remained stable, and he had no further
episodes of hematemesis. He was discharged on omeprazole.
#. Nausea/vomiting/gastroparesis: Patient has had multiple
admissions for nausea and vomiting secondary to gastroparesis
most recently discharge on [**11-23**]. It is likely that this
presentation is due to a flare of his gastroparesis. He had no
signs or symptoms of an infectious etiology. Compazine and
zofran were given for antiemetic therapy. Erythromycin and
reglan were continued for motility. He was discharged with an rx
for compazine.
#Type I diabetes mellitus: The patient presented in a
hyperglycemic state with a trend towards DKA given glucose of
288, HCO3 of 20 and AG of 16. He was started on an insulin gtt
in the ED. This was stopped in the MICU and he was restarted on
his home insulin regimen. His sugars from then on were
reasonably controlled. No changes were made to his insulin
regimen on discharge.
#Hypertension: Patient was hypertensive the ED to 210s/120s
likely secondary to distress from nausea and vomiting that
improved rapidly with antiemetic and analgesic therapy. He was
conitnued on his home lisinopril.
#End stage renal disease on hemodialysis: Patient underwent HD
on [**12-5**]. He was continued on Sevelamer, NephroCaps and Epo at
HD.
TRANSITION OF CARE ISSUES:
- Patient remained FULL CODE
Medications on Admission:
1. Sevelamer carbonate 800 mg PO TID
2. Lisinopril 20 mg DAILY
3. Metoclopramide 10 mg QID
4. B complex-vitamin C-folic acid 1 mg DAILY
5. Erythromycin 250 mg TID
6. Acetaminophen 650 mg Q6H
7. Omeprazole 20 mg DAILY
8. Lantus 5 units twice a day
9. Humalog 0-4 units sliding scale:
<150: 0 units
151-220: 1 unit
[**Unit Number **]- 290: 2 units
291- 360: 3 units
> 361: 4 units.
10. Epoetin alfa 3,000 unit/mL Solution Sig: [**2174**] units
11. Acetaminophen 1000 mg Q8H
12. Sodium chloride 0.65 % Aerosol Q4H
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times
a day.
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q8H (every 8 hours).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous twice a day.
9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
four times a day: <150: 0 units
151-220: 1 unit
[**Unit Number **]- 290: 2 units
291- 360: 3 units
> 361: 4 units.
10. epoetin alfa 2,000 unit/mL Solution Injection
11. prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
Disp:*20 Suppository(s)* Refills:*0*
12. Ocean Nasal Mist 0.65 % Aerosol, Spray Sig: One (1) spray
Nasal every four (4) hours as needed for nasal congestion.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic gastroparesis
Diabetes mellitus type I
Stage V Chronic Kidney Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 14782**],
You were admitted to the hospital because of nausea, vomiting,
and a small amount of blood in your vomit. You sugars were also
high, but you did not have signs of diabetic ketoacidosis. We
believe your nausea and vomiting was a flare of your
gastroparesis, and you symptoms improved with pain and nausea
medicines. An EGD (procedure when a doctor looks down into your
stomach with a tiny camera) did not show any abnormalities or
bleeding. The blood in your vomit was likely due to a small
tear in the lining of your esophagus from all the vomiting.
Changes to your medications:
START prochlorperazine (compazine) 25 mg twice daily per rectum
as needed for nausea
It was a pleasure to take care of you while you were in the
hospital!
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]
Appointment: Friday [**2186-12-15**] 2:40pm
|
[
"250.51",
"V58.67",
"250.61",
"530.7",
"250.41",
"493.90",
"536.3",
"585.6",
"V45.11",
"285.9",
"403.91",
"277.4",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8145, 8151
|
4268, 4523
|
332, 349
|
8287, 8287
|
3050, 3641
|
9240, 9492
|
2269, 2337
|
6881, 8122
|
8172, 8266
|
6346, 6858
|
8438, 9031
|
3657, 4245
|
2352, 3031
|
9060, 9217
|
265, 294
|
4538, 6320
|
377, 1738
|
8302, 8414
|
1760, 2099
|
2115, 2253
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,236
| 131,112
|
43234
|
Discharge summary
|
report
|
Admission Date: [**2169-7-25**] Discharge Date: [**2169-7-31**]
Date of Birth: [**2090-8-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Esophagel perforation
Major Surgical or Invasive Procedure:
[**2169-7-25**] Right thoracotomy, repair of esophageal perforation
with intercostal muscle flap.
History of Present Illness:
Mrs. [**Known lastname **] is a 78-year-old female with known common bile duct
strictures who for the past five months has been undergoing ERCP
with biliary stent placement.
Endoscopy was performed for the purposes of ERCP and a
perforation was incurred in the posterolateral left portion of
the esophagus 30-cm from the incisors. The thorascic team was
notified and the patient was taken emergently to the operating
room for repair of this perforation.
Past Medical History:
Common Bile Duct Strictures
Anemia
Constipation
Osteoporosis
PSH: several ERCPs and biliary stenting since [**1-/2169**]
Social History:
Lives alone.
Denies Tobacco or ETOH
Family History:
non-contributory
Physical Exam:
VS: T: 96.9 HR: 67 SR BP: 132/58 Sats: 96% RA
General: no apparent distress
Card: RRR, normal S1,S2 no murmur/gallop or rub
Resp: decreased breath sounds throughout
GI: bowels sounds positive abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: Right thoracotomy site clean/dry intact no erythema
Neuro: non-focal
Pertinent Results:
[**2169-7-28**] WBC-10.8 RBC-3.05* Hgb-9.6* Hct-29.4* Plt Ct-269
[**2169-7-25**] WBC-7.5 RBC-3.67* Hgb-11.8* Hct-35.6* Plt Ct-318
[**2169-7-30**] UreaN-9 Creat-0.6 Na-137 K-4.4 Cl-103 HCO3-29 AnGap-9
[**2169-7-25**] Glucose-93 UreaN-24* Creat-0.7 Na-140 K-4.3 Cl-106
HCO3-27
[**2169-7-26**] ALT-30 AST-48* AlkPhos-51 Amylase-278* TotBili-0.5
[**2169-7-30**] CXR: Status post esophageal repair. As compared to the
previous examination, there is no relevant change. Small
left-sided pleural effusion, retrocardiac atelectasis and small
right-sided pleural effusion. The previously inserted drain has
been removed. After is esophageal repair, there is no evidence
of pneumothorax.
UGI SGL CONTRAST W/ KUB Clip # [**Clip Number (Radiology) 93145**]
BARIUM ESOPHAGRAM: Evaluation of the distal esophagus was
achieved via
administration of water-soluble contrast material, followed by
thin barium. There is no extravasation of contrast from the
esophagus. Contrast material passed freely through the distal
esophagus into the stomach, which filled and emptied normally.
Minimal holdup of barium within the esophagus occurred.
IMPRESSIONS:
1. No contrast extravasation to indicate leak.
2. Retrocardiac opacity likely atelectasis, dedicated chest
radiograph
recommended.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted for ERCP a perforation was incurred in
the posterolateral
left portion of the esophagus 30-cm from the incisors. She was
referred to thoracic surgery and underwent
Esophagogastroduodenoscopy, Right thoracotomy, Primary repair of
esophageal perforation, Intercostal muscle flap and a flexible
bronchoscopy. She tolerated the procedure. She was monitored
in the SICU overnight and transferred to the floor on POD #1.
She had an Bupivacaine epidural was placed by the acute pain
service for better pain control. She continue on the Dilaudid
PCA. She had a right chest-tube, JP drain and NG in place. On
POD #2 the NG was removed. A barium swallow revealed no
esophageal leak which she was then started on a clear liquid
diet. The chest-tube was removed. On POD #3 the JP drain
remained. She was seen by physical therapy who recommended
rehab. On POD #4 the epidural was removed and she was converted
to PO pain medication with good control. The foley was removed
and she voided without difficulty. On POD #5 the JP was
removed. She was followed by the GI service throughout her
stay. On POD #6 she was started on a 14 day course of triple
therapy for H. Pylori. Her diet was advanced to a soft dysphagia
which she tolerated. She continued to make steady progress and
was discharged to rehab. She will follow-up with Dr. [**First Name (STitle) **] and
GI as an outpatient.
Medications on Admission:
Calcium Carbonate
Naproxyn
Evista
Mirilax
Discharge Medications:
1. Raloxifene 60 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO daily ().
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**First Name (STitle) **]: Five (5)
ML PO Q6H (every 6 hours) as needed for pain.
3. Ibuprofen 100 mg/5 mL Suspension [**First Name (STitle) **]: Ten (10) ML PO Q6H
(every 6 hours) as needed for mild pain.
4. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
5. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ML PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Amoxicillin 250 mg Tablet, Chewable [**Last Name (STitle) **]: Four (4) Tablet,
Chewable PO BID (2 times a day) for 14 days.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day) for 14 days.
9. Clarithromycin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day) for 14 days: crush all meds.
10. Miralax 100 % Powder [**Last Name (STitle) **]: One (1) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
Common Bile Duct strictures, anemia, constipation, osteoporosis
PSH: several ERCPs and biliary stenting since [**1-/2169**]
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office if experience:
-Fever > 101 or chills
-Increased shortness of breath or chest pain
-Difficulty or painfull swallowing, nausea/vomiting
-Incision monitor for discharge or increased redness
Chest tube site: cover site with a bandaid until healed
Complete 14 day course of Antibiotics for H. Pylori through [**8-13**]
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**8-15**] at 10:30am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Completed by:[**2169-8-1**]
|
[
"338.18",
"564.00",
"576.2",
"532.90",
"998.2",
"531.90",
"041.86",
"E870.4",
"733.00",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"42.87",
"51.10",
"97.55"
] |
icd9pcs
|
[
[
[]
]
] |
5556, 5649
|
2827, 4251
|
343, 444
|
5819, 5835
|
1532, 2804
|
6234, 6556
|
1145, 1163
|
4343, 5533
|
5670, 5798
|
4277, 4320
|
5859, 6211
|
1178, 1513
|
282, 305
|
472, 930
|
952, 1076
|
1092, 1129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,389
| 115,499
|
5787
|
Discharge summary
|
report
|
Admission Date: [**2158-6-16**] Discharge Date: [**2158-6-26**]
Date of Birth: [**2113-1-29**] Sex: M
Service: MEDICINE
Allergies:
Latex / Levaquin
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
bedside drainage of perirectal abscess
PICC line placement
History of Present Illness:
The patient is a 45 year old male with a PMHx of metastatic RCC
(papillary vs clear cell) to lungs & L pleural effusions s/p
multiple chemo regimens (most recently cycle 10 of bevacizumab +
erlotinib on [**2158-4-13**]), presents after a recent admission to
[**Hospital1 18**] for PNA now with dizziness and lightheadedness.
The patient was recently admitted from [**2158-4-10**] to [**2158-4-14**] for
dyspnea. He was started on a 14-day course of unasyn &
doxycycline for post-obstructive pna but was ultimately
discharged on augmentin. He did not, however, complete a 14-day
course; opting to stop antibiotics on [**4-18**] in hopes of being
considered for a clinical trial. He was screened for a clinical
trial for a novel anti-PDL1 antibody that required him to hold
his tarceva for 3 weeks. During this time, he appears to have
clinically deteriorated.
Most recently, he was admitted again from [**2158-5-10**] - [**2158-5-16**]
for
respiratory failure due to post obstructive pneumonia and
progressive metastatic disease to the lungs, as well as the
pleural effusion. He was given vanc/cefepime switched to
Levofloxacin for a total of 8 day course. CT scan showed mild
colitis affecting the distal descending and sigmoid colon. Stool
studies were negative for C. Diff, but he was empirically
treated
with Flagyl and completed a 2 week course of treatment.
He was again admitted from [**5-22**] to [**5-26**] for hypotension. He was
initially started on vanco/zosyn/azithromycin out of concern for
possible sepsis (given patient has recent pneumonia requiring
intubation). Antibiotics were stopped given rapid improvement of
his hypotension and it was thought his hypotension/fever was
felt to be related to underlying RCC and immulogical response by
his primary outpatient oncologist. The patient was started on
Prednisone 40mg daily on discharge.
Since being discharged, he has had increased pain in his
perineum and was evaluated by a surgeon yesterday who
recommended aspiration of a potential abscess today. He has been
n.p.o. since midnight in anticipation of the procedure. He woke
this morning and developed some lightheadedness which he has had
previously with dehydration. He denies chest pain, shortness of
breath, palpitations. He denies fever, nausea, vomiting. He
called EMS and was on a blood pressure that was not palpable
peripherally and a heart rate in the 160s, he was given a 1.5 L
of fluid in the field with improvement of his blood pressure to
be 80s and his heart rate to the 120s.
In the ED, his VS were T 97.9 HR 120 BP 83/51 RR 16 SpO2 99%/4L.
Labs significant for WBC count of 11.9, with 94% neutrophils.
Lactate 2.4. INR 1.7. Colorectal surgery was called and
recommend a CT abdomen. CT showed diffuse colitis from cecum to
hepatic flexure and stable metastatic disease, no focal abscess.
Blood and urine culutres were drawn. Given 5L NS IV. Of note,
pt refused CVL. Given Flagyl, will give CTX. Colorectal
following. On transfer, VS were BP 107/59 HR 112. No fevers
but immunosuppressed, on chemo.
On arrival to the ICU, pt is resting in bed, appears to be in
pain. States she has pain in his lower abdomen, perineum.
Rates it [**7-9**]. States the Dilaudid IV that he got in the ED
helped but wore off. Also, endorses diarrhea but not bloody or
dark stools. Denies fevers.
Past Medical History:
- Renal Cell Carcinoma
---> [**2154**]: Microscoping hematuria
---> CT A/P: 4.5 cm L adrean & periadrenal mass
---> MRI: L periaortic mass 4.6 cm
---> PET CT: lingular nodule, RP lesion adjacent to L adrenal
- [**11/2154**]: underwent resection of mass & L adrenal nodule
---> Pathology revealved metastatic adenocarcinoma of unknown
origin
---> Prominent papillary architecture w abundant eosinophilic or
clear cytoplasm & high-grade nuclear features
- PET [**2-6**]: interval increase in size & update of pulmonary
nodules
- [**3-9**]: 6 cycles carboplatin & Taxotere
---> PET CT: improvement in L lung lesions
- [**9-7**]: Enrolled in phase 1 trial of MET/ALK inhibitor
---> PET CT: Progression of disease in L adrenalectomy bed &
lungs
---> Taken off trial
- THEROS CancerType ID molecular classification test revealed
90.9% probability that cancer is of kidney origin based on 92
gene expression profile
- [**11-7**]: Sunitinib
---> Post-CT: Partial regression of adrenal bed lesion &
stability in pulmonary nodules.
---> Progressed after 6 cycles of sunitinib
- [**8-8**]: Everolimus
- [**9-8**]: Taken off everolimus for disease progression
- [**9-8**]: Cyberknife radiation for mass invading psoas muscle
---> Recovery c/b severe pain [**3-2**] inflammation
---> Fevers to 100-102, SOB, R-sided CP.
- [**10-9**]: Bronch revealed malignant cell
---> No ABPA
- [**10-9**]: Started pazopanib
- [**3-11**]: Disease progression; taken off pazopanib
- [**4-10**]: s/p 10 cycles bevacizumab & erlotinib
Past Medical History:
- Nephrolithiasis (bilateral)
- Mitral valve prolapse
- Colon polyp
- Dysplastic nevus x3
- Necrotic LN in left neck (never biopsied/cultured)
Social History:
- Anesthesiologist at [**Hospital6 **]
- Married with two young children.
- Lives in [**Location **].
- Denies ETOH/tobacco/illicits.
Family History:
- Father: Died in his 60s from brain aneurysm. Hypoplastic
kidney
- Mother: Alive in her 70s.
- All 3 sisters healthy.
Physical Exam:
admission exam
GEN: thin male, appears to be in pain
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
Neck: no LAD
CV: tachycardic, regular rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-distended; no guarding/rebounding but +ttp in LUQ
and lower abdomen
EXT: no clubbing/cyanosis/edema; 2+ distal pulses
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**6-3**] motor function globally
DERM: no lesions appreciated
.
discharge exam
Pertinent Results:
admission labs
[**2158-6-16**] 12:25PM BLOOD WBC-11.9* RBC-4.14* Hgb-10.8* Hct-37.1*
MCV-89 MCH-26.0* MCHC-29.0* RDW-21.0* Plt Ct-425
[**2158-6-16**] 12:25PM BLOOD Neuts-94.5* Lymphs-2.9* Monos-2.3 Eos-0.2
Baso-0.1
[**2158-6-16**] 12:25PM BLOOD PT-17.6* PTT-25.4 INR(PT)-1.7*
[**2158-6-16**] 12:25PM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-136
K-4.3 Cl-105 HCO3-21* AnGap-14
[**2158-6-16**] 12:25PM BLOOD ALT-79* AST-61* AlkPhos-107 TotBili-1.3
[**2158-6-16**] 12:25PM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.3
Mg-1.3*
[**2158-6-17**] 03:07PM BLOOD Type-[**Last Name (un) **] pH-7.32* Comment-GREEN TOP
[**2158-6-16**] 12:32PM BLOOD Lactate-2.4*
[**2158-6-17**] 03:07PM BLOOD freeCa-1.17
Brief Hospital Course:
45 M w metastatic RCC (papillary vs clear cell) to lungs & L
pleural effusions s/p multiple chemo regimens (most recently
cycle 10 of bevacizumab + erlotinib on [**2158-4-13**]), presents after
multiple recent admissions to [**Hospital1 18**] for PNA, presented with
hypotension and evidence of colitis on CT found to be Cdiff
positive.
.
# Hypotension: Initially thought to be [**3-2**] poor PO vs
distributive physiology from cdiff infection/rectal abscess.
Also considered adrenal insufficiency given patient on
Prednisone taper and adrenal lesion on previous imaging. He
received stress dose steroids and was subsequently transitioned
back to his home dose prednisone. Also, end-stage RCC could be
presenting with immunologic response that is causing this
hypotension. Patient??????s blood pressures remained in the 80s-100s
systolic despite fluid resuscitation and downtrending lactate.
Bedside echo did not show evidence of tamponade. His underlying
infection was treated with antibiotics. In terms of his
tachycardia, patient remained tachycardic despite adequate fluid
resuscitation. His tachycardia is likely multifactorial from
pain, underlying infection and cancer, anxiety. He had worsening
tachycardia and hypotension until the time of his death.
#Hypoxia/Shortness of breath: Patient had worsening dyspnea
throughout his stay. CT scan showed significant worsening of his
pulmonary metastases, stable pleural effusions, and a likely
pneumonia. He was started on vancomycin and cefepime for
pneumonia. He was on and off of BiPap for several days, before
his goals of care were changed towards comfort. Then he was
given IV dilaudid to relieve dyspnea.
.
# Colitis: Cdiff positive. KUB with evidence of worsening
colitis and patient with lower abdominal pain. However abdominal
exam is benign with good bowel sounds. Imaging with no evidence
of perforation or megacolon. Patient continues to be afebrile
with improving leukocytosis and decreased stool output.
Generally improving clinically from a colitis standpoint.
-resolved during ICU stay, continued on PO Vanc/Flagyl
.
# rectal abscess ?????? patient had beside I&D of a rectal abscess by
colorectal surgery (Dr. [**Last Name (STitle) **] without complication.
.
ICU Course:
Patient initially presented with presumptive shock due to c.diff
colitis, the hypotension was resolved promtply with fluid
challenge, however the patient quickly became volume overloaded
due to what was found to be new-onset heart failure with an EF
significantly depressed from previous studies. The patient had
complained of significant abdominal pain, palliative care was
consulted and the patients pain medication regimen was adjusted
with excellent symptomatic control.
-hypoxia, tachypnea, tachycardia has been omnipresent
[**6-20**]
-CTA-Chest revealed new RUL ground-glass opacities c/w likely
hemorrhage vs infectious process; the patient was started on
cefipime, vanc, and bactrim (for PCP empiric treatment). The
patient has been intermittently on bipap for respiratory
distress. The patient was given some volume back with colloid.
[**6-21**]
-Continued progression of respiratory decompensation, CT scan
findings were confirmed to be significant worsening of thoracic
tumor burden, the patient had an episode of tachypnea and
worsening tachycardia overnight which resulted in bipap,
additional doses of ativan, and lasix for diuresis. During this
time the patient declined intubation, and discussion was made
with SW/Onc/Family/MICU with little progression with regard to
end-of-life issues and critical/emergent airway management.
[**6-22**]
-the patients respiratory status continued to decline, tachypnea
persisted and the patient is reliant on a face-mask for
oxygenation, desaturating into the high 80s after less than a
minute with oxygen. A chest xray was performed which revealed
worsening edema and collapse of the RUL, likely c/w obstructive
process due to metastatic disease.
[**Date range (1) 22999**]
-the patient had persistent respiratory distress, palliative
care was consulted and the patient was started on a dilaudid gtt
for pain and respiratory distress management according to
comfort care guidelines; his ativan was titrated back to q6 with
PRN dosing maintained. Abx coverage was continued and
micafungin was added - the patient is chronically on steroids
and had previously been on chemotherapy. Despite these efforts
the patient continued to decline with persistent hypotension,
tachycardia, but improving distress symptoms likely given the
increasing titration and palliative doses of IV narcotics.
[**6-26**]
-the patient remained somnolent, unresponsive to verbal stimuli,
at rounds the patient had rapid/shallow respirations, his blood
pressures were 50's systolic with mottling of his lower
extremities and cool extremities throughout; his appearance was
noted to be peri-arrest. During rounds, Dr [**Known lastname 22998**] became
progressively hypotensive, eventually became bradycardic and
went into cardiac arrest; resuscitation was not initiated
according to standing DNR/DNI; family was present at the bedside
and the patient expired at 0950.
Medications on Admission:
oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily),
now tapered down to 20mg daily
erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Inlyta 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic renal cell carcinoma
Pneumonia
Possible pulmonary hemorrhage
Clostridium Difficile colitis
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2158-6-26**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
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12780, 12789
|
7028, 12174
|
287, 347
|
12934, 12944
|
6318, 7005
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12996, 13122
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5574, 5695
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12750, 12757
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12810, 12913
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12200, 12727
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12968, 12973
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5710, 6299
|
238, 249
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375, 3711
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5261, 5406
|
5422, 5558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,498
| 170,293
|
10435
|
Discharge summary
|
report
|
Admission Date: [**2197-5-15**] Discharge Date: [**2197-6-2**]
Date of Birth: [**2157-6-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Central line placement
Radial arterial line placement
Mechanical ventilation
History of Present Illness:
Ms. [**Known lastname 3866**] is a 39 F with widely metastatic melanoma first
diagnosed in [**11/2195**] after undergoing a biopsy of a nevus that
had changed in appearance and had become pruritic and prone to
bleeding. Pathology revealed nodular-type melanoma, invasive to
a depth of at least 4.6 mm, [**Doctor Last Name 10834**] level at least 4, extending
to the deep and lateral resection margins with ulceration
present at 8 mm. There was involvement of a sentinel lymph node
with extracapsular extension. On [**2195-11-23**], she underwent
pulmonary wedge resection of a metastatic nodule. In [**12/2195**],
she was started on a clinical trial of sorafenib. Her CT scan on
[**2196-10-17**] revealed enlargement of
several pulmonary masses and a right infrahilar azygoesophageal
mass. Additionally, she was found to have multiple brain
metastases measuring up to 2 cm. She underwent whole brain
radiation, which she completed on [**2196-12-23**]. On [**1-4**], she
started on daily Temodar but after 6 weeks of therapy she was
found to have widely progressive disease. She then elected to
undergo IL2 for her metastatic disease. Her last dose of IL2 was
yesterday ([**5-18**]) at 7 AM. Today is day 5 of cycle 1 of IL2. The
team elected to discontinue infusion because of hypoxia and
acute renal failure. The patient grew progressively more
tachypneic and hypoxic, prompting admission to the ICU. Upon
arrival at ICU, it was noted that her PO2 was 62% and the
patient's O2 sats were falling to 80's on nonrebreather. The
patient agreed to intubation, which proceded immediately.
.
ROS: denies sick contacts, admits to nonproductive cough x 2
weeks. Denies chest pain, shortness of breath, or headache, but
admits to nonbloody diarrhea.
Past Medical History:
Melanoma.
Social History:
She works at [**Company **] Pilgrim and lives with her spouse and her
son and 2 children. She has about 10-pack-year history of
smoking but quit completely. She admits to former EtOH use. Per
notes, denies any recreational drug use.
Family History:
(Per notes) Mother is alive at 59 with no medical problems.
Father has hypertension as well as some skin lesions, however,
he has never had them biopsied. She has two sisters, 36 and 31
in good health. She has a brother who is 34 in good health. She
has one daughter 9 years old who is in good health and a son 12
who is in good health.
Physical Exam:
T 96.1 BP 142/75, pulse 126, respirations 30-40, oxygen
saturation 71% room air, 91% on nonrebreather
GENERAL: A 39-year-old female very tachypneic, using accessory
muscles to breath, speaking in 1 word answers.
HEENT: Sclerae anicteric. Extraocular movements are intact.
Mucous membranes are dry.
NECK: Supple.
CARDIOVASCULAR: tachy, no murmurs, gallops, or rubs.
LUNGS: Clear to auscultation but some dullness at bases.
ABDOMEN: Soft, obese, diffusely tender throughout, nondistended,
normoactive bowel sounds present.
EXTREMITIES: No clubbing, cyanosis, but 1+ bilateral edema on
hands and feet.
SKIN: well healed scar on left axilla/shoulder.
NEUROLOGIC: Alert and oriented x3. Cranial nerves II through
XII grossly intact. Motor function [**6-10**] in all four extremities.
Pertinent Results:
CT HEAD W/O CONTRAST [**2197-5-26**] 11:13 AM
FINDINGS: There is no intracranial hemorrhage. There is no
midline shift, mass effect, or hydrocephalus. There are numerous
intracranial metastases which are better demonstrated on the
[**2197-4-26**], MRI. Please refer to that report for description
of the metastatic disease. Please note that a non-contrast head
CT is insensitive to the detection of metastatic disease,
abscesses, and vascular anomalies.
IMPRESSION: No intracranial hemorrhage. Limited exam due to lack
of IV contrast. Numerous intracranial metastases as demonstrated
on the [**2197-4-26**], MRI.
There is asymmetry of the nasopharyngeal tissues with prominence
on the right. This is a nonspecific finding which could possibly
relate to the presence of soft tissue metastases. Please
correlate with direct visualization.
.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2197-5-26**] 11:14 AM
Comparison is made with prior MRI from [**2197-4-26**]. There is
opacification of left sphenoid and bilateral posterior ethmoid
air cells with aerosolized secretions and fluid level.
Secretions are also seen in the nasal cavity and nasopharynx.
The remaining sinuses are clear. There is asymmetric prominence
of the right nasopharynx with respect to the left, clinical
correlation is advised. Bilateral ostiomeatal complexes are
patent.
No bony dehiscense.
IMPRESSION:
Mild sinusitis as above.
.
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
A right axillary node measures 15 mm in short axis diameter and
appears new. Limited non-contrast evaluation of right hilar
lymphadenopathy demonstrates that the node designated as target
lesion #1 measures approximately 43 x 26 mm (previously 35 x 24
mm). Nodal lesion 6 measures approximately 48 x 32 mm
(previously 45 x 35 mm). Adjacent target lesions 2 and 3 cannot
be adequately measured on this non- contrast study but may have
also slightly increased in size compared to [**2197-4-6**]. Left
hilar lymph nodes measuring up to 1.8 cm in short axis diameter
are again noted. There is no evidence of pericardial or pleural
effusion.
There has been progression in size and number of multiple
diffuse bilateral pulmonary metastases. A right middle lobe lung
nodule in series 2, image 33 measures 4.2 x 3.9 cm compared to
previous when it measured 3.7 x 3.5 cm. Parenchymal
consolidation at the lung bases likely represents atelectasis,
however, a superimposed infectious process cannot be completely
excluded.
Endotraheal tube terminates approximately 5cm above the carina.
Tip of NG tube is present within the stomach. Right central
venous catheter terminates near the cavoatrial junction.
CT ABDOMEN WITHOUT IV CONTRAST: Limited evaluation of the
abdomen without contrast does not adequately evaluate the
numerous liver and splenic metastatic lesions. The pancreas and
right adrenal gland appear unremarkable. A left adrenal lesion
designated lesion 5 measures 38 x 26 mm compared to prior when
it measured 36 x 28 mm. Non-contrast evaluation of the kidneys
again reveals a soft tissue mass near the mid pole of the right
kidney posteriorly, which does not demonstrate any gross change
in size. There is no evidence of free air. Multiple mesenteric
lymph nodes are again identified, some of which measure up to 15
mm and appear larger compared to [**2197-4-6**]. Non-contrast
evaluation of large and small bowel is unremarkable. Note is
made of diffuse anasarca.
CT PELVIS WITHOUT IV CONTRAST: The rectum and sigmoid are
unremarkable. Moderate free fluid is present in the pelvis and
is new compared to [**Month (only) 958**]. A left external iliac lymph node
measures 1.8 cm in short axis diameter compared to [**Month (only) 958**] when it
measured 15 mm.
Multiple scattered subcutaneous soft tissue densities have
increased in size including a 10- mm one anteriorly (2: 75) and
11-mm periumbilical one (2: 89). A left breast nodule measures
18 x 17 mm, unchanged.
Osseous structures reveal increased sclerosis around the SI
joints bilaterally likely representing sacroileitis. A small
adjacent right sacral bone island is noted.
IMPRESSION:
1. Limited non-contrast evaluation demonstrates progression of
metastatic disease with increased pulmonary tumor burden and
increase in size of multiple lymph node groups as described.
Hepatic and splenic tumor burden not adequately evaluated. Left
adrenal and right renal soft tissue lesions as described.
2. New anasarca and free pelvic fluid.
Brief Hospital Course:
Mrs. [**Known lastname 3866**] is a 39 year old woman with malignant melanoma who
received Interleukin-2 and developed hypotension, hypoxia and
fevers requiring transfer to the ICU where she was intubated and
placed on pressor agents. She was weaned from the pressors, but
required persistent respiratory support. The patient developed
oliguric renal failure, renal was consulted, but she did not
require dialysis and her kidney function returned to baseline.
She had persistently high ventilatory requirements and was
difficult to wean from the ventilator, despite treatment for
pneumonia. She contined to worsen, so CT torso was performed
which revealed worsening metastatic disease. She was made
comfort measures only and was terminally extubated on [**2197-6-2**].
Medications on Admission:
1. sertraline 25 mg a day.
2. Prilosec 75 mg a day.
3. ativan 0.5 mg PRN
Discharge Medications:
1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: or until you reach pretreatment weight.
Disp:*5 Tablet(s)* Refills:*0*
2. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for N/V.
Disp:*40 Tablet(s)* Refills:*1*
4. Diphenhydramine HCl 25 mg Capsule Sig: [**2-7**] Capsules PO Q6H
(every 6 hours) as needed for pruritis.
5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for N/V.
Disp:*40 Tablet(s)* Refills:*1*
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
7. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets
PO PRN (as needed) as needed for after each loose stool: max 8
tabs/day.
Disp:*40 Tablet(s)* Refills:*1*
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*200 ML(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic melanoma - s/p C1W1 HD IL-2 therapy
pneumococcal pneumonia
sepsis
persistent fevers
acute renal failure
Discharge Condition:
expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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[
[
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10006, 10012
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8110, 8881
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322, 401
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3627, 8087
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2472, 2810
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2826, 3608
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275, 284
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429, 2173
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2195, 2206
|
2222, 2456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,418
| 161,948
|
42197
|
Discharge summary
|
report
|
Admission Date: [**2189-10-6**] Discharge Date: [**2189-10-12**]
Date of Birth: [**2121-6-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest tightness
Major Surgical or Invasive Procedure:
[**2189-10-7**] CABG x 4: LIMA to LAD, SVG to DIAG, SVG to OM, SVG to
PDA
History of Present Illness:
68 year old male was recently referred for a stress test due to
recent atypical chest pain and a prior history of presyncope. He
also has a history of an episode of near syncope that occurred 3
years ago when he was driving in a car. He had a full work up at
that time, according to his wife and was supposed to have a
catheterization however he was unwilling to proceed with it at
that time. Over the last week, he has been experiencing
intermittent episodes of chest pain occurring unrelated to
activity or meals. He does report a lot of stress recently r/t
his son getting divorced. He describes a tightness across his
chest that lasts a few minutes and resolves spontaneously. He
has associcated left arm pain and finger numbness. He was
referred for a cardiac catheterization and was found to have
three vessel disease. He is now being referred to cardiac
surgery for revascularization.
Past Medical History:
Hyperlipidemia - did not tolerate statin meds.
History of near syncope
Hypertension
History of ETOH, Cigar smoking
History of Lyme
History of Renal calculi
Rectal fissure
Rheumatoid arthritis
Social History:
Race:Caucasian
Last Dental Exam:<1 year ago
Lives with:wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 91496**]
Occupation:Retired police officer
Cigarettes: Smoked no [x] yes []
Other Tobacco use:smokes 1 cigar/day
ETOH: < 1 drink/week [] [**12-29**] drinks/week [x] >8 drinks/week []
Illicit drug use
Family History:
Father died at 62 s/p aortic valve or aneurysm surgery 6 yrs
prior to death.
Physical Exam:
PREOP EXAM
Pulse:70 Resp:20 O2 sat:99/RA
B/P Right:151/77 Left:150/82
Height:5'[**87**]" Weight:208 lbs
General: awake alert oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA[x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] ? soft 1/6 systolic ejection murmur at left
parasternal border
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds
Extremities: Warm [x], well-perfused [x] no Edema
no Varicosities
Neuro: Grossly intact []
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2189-10-6**] Cardiac Catheterization:
1. Selective coronary angiography in this right dominant system
revealed left main and triple vessel coronary artery disease.
The LMCA had a 80% distal stenosis. The proximal LAD had an 80%
stenosis. The mid LCX had a 90% stenosis with an occluded OM1
that fills via left to left collaterals. The RCA had a 50% mid
vessel stenosis. 2. Limited resting hemodynamics revealed a
normotensive central aortic pressure of 121/72 mm Hg.
.
BLOOD WORK:
[**2189-10-12**] WBC-9.3 RBC-3.23* Hgb-9.7* Hct-29.0* MCV-90 MCH-30.2
MCHC-33.6 RDW-13.6 Plt Ct-305#
[**2189-10-9**] WBC-11.5* RBC-3.34* Hgb-10.0* Hct-29.4* MCV-88 MCH-30.0
MCHC-34.1 RDW-12.9 Plt Ct-190
[**2189-10-8**] WBC-14.7* RBC-4.04* Hgb-12.2* Hct-35.2* MCV-87 MCH-30.2
MCHC-34.7 RDW-13.1 Plt Ct-252
[**2189-10-7**] WBC-16.8* RBC-3.88* Hgb-11.5* Hct-34.2* MCV-88 MCH-29.5
MCHC-33.5 RDW-13.0 Plt Ct-273
[**2189-10-12**] UreaN-21* Creat-1.0 Na-140 K-5.0 Cl-105
[**2189-10-11**] UreaN-19 Creat-0.9 Na-139 K-4.2 Cl-105
[**2189-10-10**] UreaN-16 Creat-0.7 Na-136 K-4.0 Cl-102
[**2189-10-8**] Glucose-90 UreaN-9 Creat-0.7 Na-134 K-4.3 Cl-102
HCO3-27 AnGap-9
[**2189-10-7**] UreaN-12 Creat-0.8 Na-138 K-4.5 Cl-108 HCO3-25 AnGap-10
[**2189-10-12**] Mg-2.5
[**2189-10-6**] %HbA1c-5.7
.
[**2189-10-11**] Chest X-ray:
As compared to the previous radiograph, the patient has made a
stronger inspiratory effort. On the left, there is a minimal
pleural effusion and a small plate-like atelectasis. The
right-sided internal jugular vein catheter has been removed. No
pneumonia, no pulmonary edema. Borderline size of the cardiac
silhouette after CABG.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted after cardiac catheterization revealed
severe three vessel cornary artery disease - see result section
for details. Cardiac surgery was therefore consulted and
preoperative evaluation was performed. He agreed to proceed with
surgical revascularization and was cleared for surgery. The
following day, Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting
surgery. For surgical details, please see operative note. After
surgery, patient was brought to the CVICU for invasive
monitoring. Within 24 hours, patient awoke neurologically intact
and was extubated without incident. He maintained stable
hemodynamics and transferred to the cardiac SDU on postoperative
day one. Amiodarone was started for paroxysmal atrial
fibrillation while betablockade was advanced as tolerated. He
remained mostly in a normal sinus rhythm, Warfarin was therefore
not initiated. Over several days, he continued to make clinical
improvements with diuresis and was cleared for discharge to home
with VNA on postoperative day five. Prior to discharge, all
followup appointments were arranged.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet -
0.5
(One half) Tablet(s) by mouth daily
NEBIVOLOL [BYSTOLIC] - (Prescribed by Other Provider) - 5 mg
Tablet - 0.5 (One half) Tablet(s) by mouth daily
MAGNESIUM OXIDE-PYRIDOXINE HCL [BEELITH] - (Prescribed by Other
Provider) - 362 mg-20 mg Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: then drop to 1(one) tablet [**Hospital1 **](twice daily)
for 7(seven) days then drop to 1(one) tablet daily.
Disp:*60 Tablet(s)* Refills:*1*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days: please
take with Lasix.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: please take with KCL.
Disp:*7 Tablet(s)* Refills:*0*
11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Hypertension
Dyslipidemia
Postop Paroxysmal Atrial Fibrillation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage
Edema: 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) **] [**2189-11-12**] at 1:00pm [**Hospital Ward Name **] [**Hospital Unit Name **]
Wound check on [**2189-10-22**] at 10:30am [**Hospital Ward Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] [**2189-10-23**] at 1:45pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-24**] 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:[**2189-10-12**]
|
[
"427.31",
"564.09",
"414.01",
"997.1",
"714.0",
"401.9",
"272.4",
"V13.01",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"37.22",
"36.15",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7393, 7442
|
4367, 5492
|
327, 403
|
7584, 7817
|
2713, 4344
|
8657, 9386
|
1903, 1982
|
5882, 7370
|
7463, 7563
|
5518, 5859
|
7841, 8634
|
1997, 2694
|
272, 289
|
431, 1326
|
1348, 1542
|
1558, 1887
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,536
| 132,839
|
10785
|
Discharge summary
|
report
|
Admission Date: [**2101-5-9**] Discharge Date: [**2101-5-14**]
Date of Birth: [**2073-2-2**] Sex: F
Service: MEDICINE
Allergies:
Zantac / Reglan
Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 2470**] is a 28 year-old female with Type I DM c/b
gastroparesis, ESRD on HD M/W/F, recent diagnosis of PE on
coumadin, who presents with RUQ abdominal pain, nausea, and
vomiting after missing her last 2 HD sessions. The patient
reports that this episode is similar to previous gastroparesis
flares. No CP or SOB.
.
In the ED, initial VS were: T 97.3, P 98, BP 209/128, RR 16,
O2sat 100 RA, pain [**11-6**]. IV access was initially difficult to
obtain; ynable to place RIJ (h/o multiple failed attempts) so R
femoral line placed under sterile conditions in ED. Pt was
given droperidol 5 mg for nausea and morphine 4 mg for pain. K
was found to be elevated to 7.4. EKG showed peaked T waves.
She was given 1 amp D50, insulin 10 units, and 1 amp calcium
gluconate. Repeat K was 7.5. Renal was consulted, and pt was
admitted to the MICU for emergent HD. On transfer, T 98, P
100s, BP 123/71, RR 14, O2sat 100 RA.
.
On the floor, pt is responsive to voice but somnolent and unable
to provide a history.
.
Past Medical History:
# Type 1 diabetes diagnosed at age 12. H/o medication
noncompliance. A1c 9 in [**7-6**]. Recent admission for DKA from
[**Date range (1) 35229**]
# ESRD on HD (fistula on RUE for access)
# RLL subsegmenta pulmonary embolus on [**2101-4-25**] CTA chest.
# Ovarian cyst diagnosed at [**Hospital 47**] Hospital.
# History of gonorrhea when she was 16 years old which was
treated.
# History of Chlamydia s/p treatment
# Migraine headaches
Social History:
Smokes ~3 cigarettes daily; started smoking at age 18 x 1 year,
quit for 1 year, and recently started again. Denies any alcohol
or drug use now or in the past.
Family History:
Her father has AIDS. Her mother has diabetes and lupus. She also
has some sort of liver problem. There are multiple other people
in her family with diabetes. No known coronary artery disease or
cancers.
Physical Exam:
General: Somnolent, minimal verbal responsiveness to verbal
stimuli although is able to follow basic commands.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Mild rales over posterior bases, no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur, no rubs or gallops
Abdomen: Soft, non-tender, mildly-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, RUE fistula with palpable thrill, R femoral line in place
oozing blood
Neuro: PERRL, nl tone, purposeful movements in all extremities,
negative Babinski bilaterally
Pertinent Results:
[**2101-5-9**] 09:40PM BLOOD WBC-10.8 RBC-4.17* Hgb-12.3 Hct-38.8
MCV-93 MCH-29.6 MCHC-31.8 RDW-17.0* Plt Ct-356
[**2101-5-9**] 09:40PM BLOOD PT-27.0* PTT-35.0 INR(PT)-2.6*
[**2101-5-9**] 09:40PM BLOOD Glucose-148* UreaN-41* Creat-10.0*#
Na-139 K-7.4* Cl-104 HCO3-19* AnGap-23*
[**2101-5-9**] 09:40PM BLOOD Calcium-8.6 Phos-7.2*# Mg-2.6
[**2101-5-10**] 06:32AM BLOOD TSH-0.23*
[**2101-5-10**] 06:32AM BLOOD T4-7.8
[**2101-5-10**] 06:32AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Assessment and Plan: 28 yo F with history of DM1, ESRD on HD who
presents with abdominal pain, nausea, and vomiting found to be
hyperkalemic
.
# Hyperkalemia: She was found to be hyperkalemic with EKG showig
peaked T-waves after missing at least two sessions of
hemodialysis. She was given insulin, D50, calcium gluconate and
hemodialysis was pursued. The renal team was consulted. Her
lisinopril was initially held. Her hemodialysis was completed
uneventfully.
.
# ESRD on HD: She underwent emergent hemodialysis following
placement of the temporary catheter in the emergency department.
The renal team was consulted. She was continued on sevelemer. A
social work consult was placed given history of missed
hemodialysis sessions.
.
# Somnolence: Likely due to administration of morphine and
droperidol in setting of ESRD as was reportedly mentating at
baseline initially on ED arrival. Her mental status quickly
improved and sedating medications were avoided.
.
# Anion gap metabolic acidosis: AG = 16. [**Month (only) 116**] have degree of
uremia. With abd pain, concern for lactic acidosis although pt
unlikely to have ischemic bowel, especially given benign exam.
Glucose level not c/w DKA. Her lactates and electrolytes were
monitored. Her anion gap resolved without intervention.
.
# RUQ pain/N/V: Per ED history, symptoms typical of
gastroparesis. Has had similar pain in past with DKA
presentation but labs not consistent with this today. Alk phos
elevated but other LFTs nl, c/w prior labs. Lipase nl. Pt
currently without TTP on exam s/p morphine although somnolent.
N/V could occur in setting of uremia although BUN only 41.
Her abdominal exam remained benign throughout the admission.
# Hypertension: Initially very high on presentation, likely due
to pain. Improved with pain control. Her anti-hypertensives
were initially held in the setting of GI bleed (see below), but
labetalol and clonidine were restarted at her home doses prior
to discharge.
Her lisinopril was initially held in the setting of acute renal
failure.
.
# Diabetes Type I: Her fingersticks were initially low in the
setting of receiving insulin for hyperkalemia. She was given one
amp of D50 with improvement in blood sugars. She was restarted
onher home insulin regimen of 12 lantus Qhs and insulin sliding
scale.
.
# Pulmonary embolism: She was recently found to have a RLL
subsegmental PE on [**2101-4-25**]. Her INR was initially therapeutic.
She was continued on coumadin 4mg q 4pm until her episode of
maroon stool described below. At that time, risks and benefits
of anticoagulation were weighed, and her coumadin was held. Her
anticoagulation was not able to be restarted prior to the
patient leaving the hospital against medical advice.
# Marked Hematocrit Drop: Patient was noted to have hematocrit
drop from 30 to 17. The patient had oozing from right femoral
line site after its discontinuation for 1-2 days, as well as her
usual menses. She was also noted to have maroon stool. She was
transferred to the ICU where she received 2 units of FFP and 2
units of pRBCs. Her hematocrit bumped appropriately to 25 and
then continued to rise towards 28. No further episodes of
bleeding were noted, and her hematocrit remained stable.
GI was consulted and stated they would likely perform a
colonoscopy after the patient has been stabilized and returned
to the regular medical floor. Unfortunately, the patient left
the hospital against medical advice prior to her tranfer to the
floor.
On the evening of discharge, the patient became very tearful and
upset regarding her length of hospitalization. She expressed
her wishes to the leave the hospital against medical advice.
A long discussion was had with the patient by the intern,
resident, and attending physician [**Name Initial (PRE) 35230**]. The risks of
leaving the hospital, including infection, continued bleeding,
and death were discussed with the patient. She verbalized
understanding of these risks after which she signed a discharge
against medical advice form.
Her PICC line was removed and the patient left the hospital. An
email was sent to her PCP informing her of these events.
Medications on Admission:
# Lisinopril 5 mg daily
# Labetalol 100 mg [**Hospital1 **]
# Clonidine 0.2 mg/24 hr Patch q Mon
# Gabapentin 200 mg [**Hospital1 **]
# Sevelamer Carbonate 800 mg tid w/ meals
# Camphor-Menthol 0.5-0.5 % Lotion qid prn itching
# Warfarin 4 mg q 4pm
# Insulin glargine 12 units at night with HISS
# Colace prn
# Bisacodyl prn
Discharge Medications:
# Labetalol 100 mg [**Hospital1 **]
# Clonidine 0.2 mg/24 hr Patch q Mon
# Gabapentin 200 mg [**Hospital1 **]
# Sevelamer Carbonate 800 mg tid w/ meals
# Camphor-Menthol 0.5-0.5 % Lotion qid prn itching
# Insulin glargine 12 units at night with HISS
# Colace prn
# Bisacodyl prn
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- End stage renal disease on hemodialysis
- Type I diabetes mellitus
- Hyperkalemia
- Hyperglycemia
Secondary:
- Hypertension
- Chronic pain
Discharge Condition:
Alert, oriented, ambulatory. Last BP check prior to departure
was elevated at 174/110 and HR 118.
Discharge Instructions:
None provided - patient left AMA.
[**Hospital1 **] Instructions:
None provided - patient left AMA.
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]
Completed by:[**2101-5-17**]
|
[
"285.1",
"787.01",
"584.9",
"250.13",
"583.81",
"E879.1",
"998.12",
"789.01",
"536.3",
"585.6",
"V15.81",
"250.43",
"288.60",
"403.91",
"276.7",
"250.63",
"790.92",
"346.90",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"38.93",
"97.49"
] |
icd9pcs
|
[
[
[]
]
] |
8326, 8332
|
3485, 7646
|
289, 296
|
8526, 8625
|
2961, 3462
|
2009, 2214
|
8022, 8303
|
8353, 8505
|
7672, 7999
|
8649, 8684
|
2229, 2942
|
235, 251
|
324, 1357
|
1379, 1815
|
1831, 1993
|
8715, 8912
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,957
| 141,851
|
3186
|
Discharge summary
|
report
|
Admission Date: [**2136-9-4**] Discharge Date: [**2136-9-10**]
Date of Birth: [**2056-4-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
palpitations at home
Major Surgical or Invasive Procedure:
VT ablation [**9-5**]
History of Present Illness:
80 y/o woman with known CAD s/p 2 vessel CABG (10 yrs ago),
ischemic cardiomyopathy, CHF last echo [**7-1**] (EF 25%), moderate
to severe MR, LBBB, persistent Afib (s/p biventricular pacer and
atrioventricular nodal ablation, end of [**2136-6-27**]) and COPD,
now presents after palpitation episode at home.
Mid [**2136-6-27**], the pt presented to [**Hospital6 33**] with
significant heart failure, with Afib and LBBB. She had an ICD
placed ([**2-29**] body habitus, comorbid conditions and age). After
the ICD was placed, she underwent AV junction ablation, which
was successful. She had intermittent episodes of palpitations
("couples of episodes over the last week") without chest pain,
diaphoresis, dizziness, lightheadedness or syncope. No arm
numbness or shoulder pain. One day PTA, she had 2 similar
episodes, one of which lasted a few minutes, and one which
persisted and prompted her to call EMS. In the ambulance, she
was found to have a wide complex tachycardia (rate 180-200),
cycling 310 msec with superior axis morphology based on a 3 lead
rhythm strip in the ambulance. This spontanceously converted.
She was given IV adenosine 6mg then 12mg, and 100mg lidocaine,
and then spontaneously reverted back to NSR. In the ER, was in
NSR and loaded with 150mg amiodarone and then amiodarone gtt
then had another episode of tachyarrhythmia. EP fellow put a
magnet over her which converted her to VOO, back to NSR. She is
being v-paced in the 70s. She was subsequently admitted to CCU
for further mgmt. Initial CE negative.
.
Last echocardiogram was [**2136-7-21**]:
LV is significantly dilated. Severe hypokinesis involving all
segments of the left ventricle though the apex is akinetic.
Left V fxn is severly reduced and estimated LVEF of 20-25%.
Aoric valve leaflets are mildly thickened without restriction to
flow. 4+MR [**First Name (Titles) 151**] [**Last Name (Titles) 13174**] of flow in the pulmonary veins. Left
atrium is enlarged to 4.6cm. RA nl. Right [**Last Name (Titles) 14965**] size is
nl. Moderately severe TR. PA systolic pressure of 65mm Hg.
Past Medical History:
1. CAD s/p CABG [**41**] years ago, says she has had a stent placed
since then (does not know exact date)
2. severe ischemic cardiomyopathy, CHF with EF 20%
3. severe MR, severe TR
4. atrial fibrillation tx with biventricular pacer for
bradyarrhythmias ([**June 2136**]), and then with persistent Afib, had
an AV nodal ablation
5. COPD
6. Hypothyroidism
Social History:
Returned from rehab, and lives with her son and daughter-in-law.
She was a smoker who quit but 30 years X 1ppd. She does not
use alcohol. No IVDA.
.
Family History:
Son- diabetes [**Name2 (NI) **], HTN, obesity
Son- muscular dystrophy
Physical Exam:
Physical Exam:
Temp: 98.6 BP: 106/60 P: 91 RR: 18 Oxygen saturation: 97% on
2L NC
General: No apparent distress. Propped up on 2 pillows,
breathing with accessory muscles.
HEENT: PERRL, MMM
Neck: JVD to the earlobe, supple, good ROM
Lungs: With bilateral crackles halfway up the lung fields. No
wheezes.
CV: With systolic murmur at the apex and systolic ejection
murmur at RUSB
Abd: Soft, NT, ND, NABS, No masses.
Ext: 2+ DP pulses, 2+ radial pulses, symmetric. Trace edema.
No cyanosis/clubbing.
Neuro: Responses appropriate, No focal deficits. CN 2-12
intact bilaterally. Sensory intact.
Brief Hospital Course:
Impression: 80y/o woman with history of CAD s/p 2 vessel CABG
[**41**] years ago, Afib s/p BiV pacer s/p ablation with persistent
paroxysmal Afib, COPD, now presents with palpitations,
tachyarrhythmia and CHF.
1. Tachyarrhythmia, wide complex rate 180-200, currently
resolved: The patient was begun on an amiodarone drip. She was
without further tachyarrhythmia during her CCU admission. She
was monitored on telemetry, with Dr. [**Last Name (STitle) 73**],
Electrophysiology, following her. She underwent a successful VT
ablation by Electrophysiology. Daily EKGs were completed. She
was felt to be stable on her medication, and will be discharged
home on amiodarone with follow up with Dr. [**Last Name (STitle) 73**].
2. Congestive Heart Failure/Ischemic Cardiomyopathy: Her
recent echo at OSH ([**7-1**]) shows EF: 20-25%. Aoric valve
leaflets are mildly thickened without restriction to flow.
4+MR. [**First Name (Titles) 167**] [**Last Name (Titles) 14965**] size is nl. Moderately severe TR. She
had flat cardiac enzymes. We held her digoxin, and continued
her aldactone, lasix, ASA. We also held her ACEI as she had low
blood pressures during her admission. We diuresed her with IV
lasix for fluid goal -1L per day during her admission. Her
discharge CXR was read as "mild pulmonary edema which continues
to clear, small bilateral pleural effusions, partially fissural
on the right, improving. Severe cardiomegaly is stable." She
will be discharged with a f/u appt with Cardiology to follow her
CHF.
3. Coronaries:
ASA was continued, and a lipid panel was checked, with her
cholesterol being 182, Triglycerides 1121, HDL 66, and LDL 94.
She was started on a statin. Her beta blocker was continued.
4. Pump: EF 20-25% We initially held digoxin, then added it
back, diuresed her with fluid goal -1L per day. Her digoxin
level at the OSH was 1.6. Her pulmonary edema improved over her
hospital course.
5. Electrical: as above tachyarrhythmia, h/o Afib
The patient was on coumadin on admission. She was also started
on an amiodarone gtt for rhythm management during her stay, and
will be discharged on amiodarone with follow up with cardiology
and Dr. [**Last Name (STitle) 73**].
6. Pulmonary: h/o COPD, using accessory muscles to breathe, but
family reports she has been breathing this way for months. CXR
revealed pulmonary edema with bilateral pleural effusions, which
continued to improve over her hospital stay as she was diuresed.
She will be discharged on lasix. Her ABG and sats were stable.
We continued her advair diskus, initially holding her spiriva.
She can follow up with her PCP, [**Name10 (NameIs) **] cardiology to re-start
Spiriva.
7. Hypothyroidism
Her TSH at OSH was normal. Her TSH was rechecked here, and
found to be 1.2 (normal). We continued her levothyroxine, home
dose. She should follow up with her PCP for periodic checks on
her TSH.
8. DNR/DNI- Had conversation which was documented. Dr.
[**Last Name (STitle) 73**] was notified and this was documented online.
Medications on Admission:
Meds on transfer:
1. Coumadin 5mg po qd
2. Amiodarone 200mg po qd
3. Lisinopril 2.5mg po qd
4. Levothyroxine 100mcg po qd
5. Advair Diskus 250/50 one puff twice daily
6. Spiriva 1 puff daily
7. Lasix 20mg po bid
8. Aldactone 12.5mg po qd
9. Trazodone 25mg po qHS
10. Ultram 50mg po q4h prn pain
11. Digoxin 0.125mg po qd
12. Colace 100mg po bid
13. Aspirin 81mg po qd
14. Dulcolax 20mg po q3days prn constipation
.
Discharge Medications:
1. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs Disk with Device(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO qAM.
Disp:*45 Tablet(s)* Refills:*2*
12. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO at bedtime.
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
1. wide complex tachycardia status post VT ablation [**2136-9-5**]
2. Atrial fibrillation status post biventricular pacer and AV
nodal ablation
3. Coronary Artery Disease status post coronary artery bypass
graft 10 years ago
4. ischemic cardiomyopathy
5. congestive heart failure
6. mitral regurgitation
7. left bundle branch block
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: 2L
If you experience chest pain, shortness of breath, sweating,
please report to the ER immediately.
Please take all of your medications and please follow up with
your doctors (see information below).
Followup Instructions:
1. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14966**], your primary care
physician. [**Name10 (NameIs) 357**] call his office at [**Telephone/Fax (1) 14967**] as soon as
possible.
2. Please follow up with Dr. [**Last Name (STitle) 73**],
Electrophysiology/Cardiology. Your appointment is for [**11-2**], [**2136**] at 11:30am. This is in [**Hospital Ward Name 23**] [**Location (un) 436**]. His office
number is ([**Telephone/Fax (1) 12468**].
Completed by:[**2136-10-30**]
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59,411
| 151,021
|
1357
|
Discharge summary
|
report
|
Admission Date: [**2161-9-22**] Discharge Date: [**2161-10-1**]
Date of Birth: [**2095-8-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Decompensated CHF
Major Surgical or Invasive Procedure:
Cardiac catheterization
Dialysis
Ultrafiltration
Femoral central line placement
Nasogastric Tube Placement
PICC line placement
History of Present Illness:
66 year old [**Location 7972**] man with systolic CHF, ESRD on
dialysis, COPD, hypertension, hyperlipidemia, peptic ulcer
disease, h/p CVA who presented with respiratory distress. The
patient was due for HD on Tuesday, the day of admission, but
became increasingly short of breath throughout the evening,
especially in the last two hours prior to calling EMS. When EMS
arrived, the patient was wheezing, diaphoretic, using accesory
muscles. Of note, the patient endorsed eating Chinese food the
evening prior but did go to hemodialysis and had been compliant
with all his medications. The patient was recently hospitalized
on the Medicine Service ([**2161-9-18**]) for dyspnea thought to be due
to fluid overload. On that admission he had increased his PO
fluid intake in the setting of the heat and lost his advair
inhaler. A proBNP was [**Numeric Identifier 8189**] in the ED on last admission.
.
In the ED, initial vital signs were: T 98.3 P 115 BP 215/102 R
22 O2 sat 100% on ?. His history was very limited by respiratory
distress and on physical exam, lungs very tight with diffuse
wheezing. The patient received duonebs, steroids. He failed
trial of bipap and received rocuronium and was intubated,
sedated with propofol. His labs were notable for lactate 2.1,
leukocytosis to 19.4 with no bands, BNP [**Numeric Identifier 8269**]. Troponin 0.07 in
the setting of Cr 9.7. Urinalysis negative. UTox negative. CXR
showed congestion suggestive of CHF exacerbation but could not
rule out opacities. The patient was felt to have been in
respiratory failure secondary to fluid overload with a component
of COPD flare, requiring urgent dialysis. He acutely developed
wide complex tachycardia, was found to have a blown right pupil
(unclear baseline exam) and EKG concerning for STEMI. The
patient [**Numeric Identifier 1834**] CT head for the blown right pupil which showed
no intracranial hemorrhage.
.
Cardiology was consulted and Code STEMI was called. The patient
was admitted to the CCU from the Cath Lab. ECHO showed EF
30-35%. In the CCU, Neurology was consulted who reviewed the CT
head and felt he had not had an acute stroke. His dilated right
pupil resolved and was felt due to albuterol exposure of the
right eye. Right femoral line was placed when it was noticed
that the patient had blueness and mottling of his foot; [**Numeric Identifier **]
Surgery was called who recommended STAT removal of sheath and
heparinization, with which the leg turned pink. Heparin gtt was
continued for LV thrombus concerns. He was dialyzed with 400cc
fluid removal, with vast improvement in pulmonary status
(negative 1.4L length of stay) and the patient was extubated. He
started complaining of abdominal pain (RUQ) the morning of
[**9-22**] and given maalox/simethicone.
.
The patient was called out to [**Hospital Ward Name 121**] 2 where he continued to have
abdominal pain which improved with bowel movements, LFTs normal.
This morning, [**9-24**], the patient developed severe abdominal
pain with radiation to the back. MICU was called to evaluate the
patient. There was concern for peritoneal signs and he [**Month (only) 1834**]
CTA which showed pancreatitis. Lipase also 208. In this setting,
he was transferred to MICU for pain control and volume
resuscitation with need for close monitoring as he is anuric at
baseline with EF 30-35% and could require intubation/CVVH for
pancreatitis management.
Past Medical History:
1. COPD (Last Spirometery [**2-24**] FEV1 41% of predicted c/w GOLD
severe to Very Severe COPD depending on Symptoms, DLCO mildly
Reduced in '[**54**])
2. ESRD (on HD since [**2160-10-1**])
3. hypertension
4. hypercholesterolemia
5. peptic ulcer disease
6. colocutaneous fistula status post low anterior resection,
colostomy, and a loop ileo-ostomy [**2154**]
7. history of pneumonia
8. bilateral carotid artery stenosis s/p left carotid
endartectomy [**2160-4-3**]
9. h/o left frontoparietal stroke
10. systolic CHF (LVEF 45-50% on [**2161-8-12**])
Social History:
He lives with his daughter, he is retired from instructing at a
driving school. He has a significant smoking history, but quit
in [**2160-3-17**]. He endorses drinking varying amounts of
whiskey and beer daily but denies drug use. Per further
questioning of his daughter, patient reportedly drinks up to a
bottle of whiskey a night.
Family History:
Brother is on dialysis as a complication of type 2 DM. Mother
also had diabetes.
Physical Exam:
ADMISSION EXAM
VS: T=96 BP=122/64 HR=102 RR=16 O2 sat=98% CMV 50% 450x16
GENERAL: Grimacing to pain. intubated sedated
HEENT: R. Pupil 7mm, non responsive, L. Pupil proptotic with
pinpoint. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP above jawline at 30 degress cm.
CARDIAC: L chest wall abnormality with Left chest elevated. PMI
non-palpable RR only auscultated in the tricuspid and mitral
areas distant, though as far as I can tell normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: L chest wall deformity as above. Intubated, ventilating
easily. No wheezes, rales in all fields on anterior exam.
ABDOMEN: Obese Soft, NTND. Liver edge irregular, palpable to 2cm
below the costal margin. Abd aorta not enlarged by palpation.
No abdominial bruits.
SKIN: R. Foot mottled, no edema.
PULSES:
Right: R. Foot is mottled, cold below the knee.
Carotid 2+ Femoral doppler with sheeth in Popliteal 0 DP 0 PT 0
Left: Carotid 2+ Femoral 2+ Popliteal dopplerable DP dopplerable
PT dopplerable (exam at SBP of 180).
Neuro: Not following comands on propofol. Grimacing to pain.
Initially not moving hands but did move right hand during
contrast bolus. Moving both feet spontaneously. R. Eye blown,
7mm nonresponsive, left eye pinpoint reactive. proptotic.
.
DISCHARGE EXAM
Pertinent Results:
Laboratory Data:
[**2161-9-22**] 06:01AM WBC-19.4*# RBC-5.34# HGB-17.2# HCT-53.9*#
MCV-101* MCH-32.3* MCHC-32.0 RDW-14.8
[**2161-9-22**] 06:01AM cTropnT-0.07* proBNP-[**Numeric Identifier 8269**]*
[**2161-9-22**] 06:01AM GLUCOSE-128* UREA N-64* CREAT-9.7*#
SODIUM-141 POTASSIUM-6.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-24*
[**2161-9-22**] 06:16AM LACTATE-2.1*
[**2161-9-22**] 10:11AM TYPE-ART O2-100 PO2-222* PCO2-74* PH-7.18*
TOTAL CO2-29 BASE XS--2 AADO2-422 REQ O2-73 INTUBATED-INTUBATED
[**2161-9-22**] 12:59PM BLOOD Glucose-184* UreaN-74* Creat-10.8*#
Na-138 K-7.8* Cl-102 HCO3-23 AnGap-21*
[**2161-10-1**] 06:07AM BLOOD WBC-9.8# RBC-2.79* Hgb-9.0* Hct-27.3*
MCV-98 MCH-32.2* MCHC-32.9 RDW-14.6 Plt Ct-316
[**2161-10-1**] 06:07AM BLOOD Glucose-155* UreaN-47* Creat-8.1* Na-138
K-4.2 Cl-93* HCO3-33* AnGap-16
[**2161-10-1**] 06:07AM BLOOD Calcium-7.9* Phos-5.2* Mg-2.1
Studies:
- ECG:
initially wide complex with diffuse ST-Elevation
.
Currently: narrow but widening QRS', PR normal, Leftward axis,
sinus rate of 99, ST depressions horizontal I, II, III, aVF, ?q
V2, Concave ST-elevations v1-v3, TWI with horizontal ST
depressions v4-v6. Significantly changed from [**9-17**].
.
- ECHO:
[**9-22**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is severe regional left ventricular systolic
dysfunction with septal, inferior and apical akinesis. Views
suboptimal for assessment of regional wall motion; estimated
left ventricular ejection fraction ?20-25%. Cannot exclude left
ventricular apical thrombus. Doppler parameters are most
consistent with Grade III/IV (severe) left ventricular diastolic
dysfunction. Right ventricular chamber size is normal. with
focal hypokinesis of the apical free wall. The aortic valve is
not well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
.
Compared with the prior study (images reviewed) of [**2161-8-12**],
regional wall motion abnormalities are now more extensive
(previously there was basal inferoseptal and basal inferior
hypokineiss/akinesis and mid to apical anterior
hypokinesis/akinesis).
.
[**9-22**]- CTA head
1. Multiple areas of calcific and non-calcific atherosclerotic
plaque causing 40% narrowing of the right internal carotid
artery at the bulb with a short area of severe narrowing of the
right external carotid artery just past its origin. No aneurysms
noted.
2. Bilateral large consolidations with multiple enlarged lymph
nodes noted
within the mediastinum.
3. Focal area of hypodensity in the left pons is unchanged and
age
indeterminate. An MR may be obtained for further evaluation.
4. Moderate proptosis of both globes could be related to [**Doctor Last Name 933**]
disease
although the extraocular muscles are normal in morphology.
.
[**9-22**] Cardiac cath
Final report not available. Per report, 70-80% RCA lesion, not
intervened on.
.
[**9-23**] Cardiac Echo
FOCUSED STUDY for evaluation of left ventricular thrombus. Only
subcostal views obtained. There is mild symmetric left
ventricular hypertrophy. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
ejection fraction moderate to severely depressed.No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size is normal. with mild global free wall hypokinesis.
There is a trivial/physiologic pericardial effusion.
[**9-24**] CT angiography of the Abdomen
IMPRESSION:
1. Diffusely enlarged and heterogeneous pancreas with
surrounding stranding and free fluid, is consistent with acute
pancreatitis.
2. No evidence of mesenteric ischemia.
3. Hypodense structure is visualized in the right lobe of the
liver with
Hounsfield units which are too high for a simple cyst. A
dedicated MRI on a non-emergent setting is recommended.
4. The left adrenal gland appears bulky. A dedicated MRI is
recommended in a non-emergent setting.
[**9-25**] Abdominal Ultrasound
IMPRESSION:
1. Normal gallbladder without evidence of stones or sludge.
2. Atrophic echogenic kidneys consistent with end-stage renal
disease.
3. Splenomegaly.
Abdominal x-ray [**2161-9-28**]
ABDOMEN, PORTABLE: Air is identified in the small and large
bowel. The transverse colon is now dilated to 7.6 cm (previously
7.3 cm). Air is identified in the rectum.
IMPRESSION: Increasing adynamic ileus.
.
L upper extremity doppler [**2161-9-28**]
IMPRESSION: No significant arterial obstruction in the upper
extremities.
.
CXR [**9-29**]:
FINDINGS: Single portable frontal view of the chest shows no
progression of
the atelectasis seen in the left lung base and right minor
fissure. No
pleural effusion or pneumothorax. The heart size is unchanged.
Again seen is a left PICC line whose tip terminates within the
SVC. There has been removal of an OG tube.
Brief Hospital Course:
HOSPITAL COURSE
66yo [**Location 7972**] man with past medical history of congestive
heart failure, end-stage renal disease on dialysis, HTN, who
initially presented with respiratory distress and was intubated
in the ED, found to have STEMI, s/p cardiac catheterization
demonstrating mid-RCA lesion 70-80% that was not intervened
upon, was subsequently extubation, course complicated by
pancreatitis, now improved.
.
# STEMI, Hyperkalemia, Acute Systolic CHF, End-stage Renal
Disease
Patient initially presented hypoxic, thought to be due to acute
systolic heart failure and fluid overload. In the ED, in the
setting of hyperkalemia, the patient developed wide-complex
tachycardia with ST changes concerning for a STEMI, and the pt
was urgently transferred to cath lab. On cardiac catheterization
an 80% occlusion of the RCA was found, and the pt was noted to
have markedly elevated right-sided pressures and wedge pressure.
The cardiology team opted for medical management of the RCA
lesion, and the patient was transfered to the CCU for urgent
dialysis. Patient was dialyzed with improvement in pulmonary
status and quickly extubated. A subsequent ECHO showed EF
30-35%. The pt was continued on atorvastatin, plavix, ASA.
Continued HD Tues/Thurs/Saturday, nephrocaps.
#COLD RIGHT FOOT WITH [**Location **] SURGERY CONSULT:
During cardiac catheterization, a right femoral line was placed
and shortly after the pt developed blueness and mottling of his
foot; [**Location **] Surgery was called who recommended STAT removal
of sheath and heparinization, with which the leg turned pink.
#BLOWN PUPIL WITH NEUROLOGY CONSULT
Following cardiac catheterization, patient was found to have a
blown right pupil which was not present on previous admission.
The patient [**Location 1834**] CT head for the blown right pupil which
showed no intracranial hemorrhage. The neurology team was
consulted, reviewed the CT head, and felt he had not had an
acute stroke. His dilated right pupil resolved and was felt due
to albuterol exposure of the right eye. Another potential
etiology that was entertained was cholesterol emboli which would
unite the cold right foot and pancreatitis with this condition.
#ACUTE PANCREATITIS:
On [**2161-9-24**] after transfer to the medical floor, the patient
developed abdominal pain, was noted to have elevated lipase
>200. The pt did endorse drinking whiskey and beer daily prior
to admission. CT c/w diagnosis of acute pancreatitis w/o signs
of complications including no gallstones of biliary dilation.
Patient was transferred to ICU to receive fluids in concert with
dialysis. Patient was made NPO and was started on dilaudid PCA.
Pain improved over 24 hours; diet was slowly adanced. There was
question of ileus on KUB although no clinical signs were
apparent. Diet was advanced with transition from PCA to oral
analgesia. On discharge, patient was taking PO and was moving
his bowels, but still requiring occasional (twice daily) oral
narcotics.
# ANEMIA: Nadir of 25.5, down from 29-30s, normocytic: MCV 95,
RDW 14.4. Anemia was attributed to anemia of chronic disease
with no evidence of acute blood loss. Hematocrit was stable
upon discharge following an injection of epopoietin.
# Hypertension: Patient was noted to be hypertensive during the
hospitalization and his metoprolol was increased from 50 to 75mg
total daily. We also added on amlodipine 5mg daily. This can
be titrated as appropriate as an outpatient. The patient was not
on an ACE inhibitor or [**Last Name (un) **] on admission, but the reasons for
this were unclear. This will need to be followed up with his
PCP.
# Occasional episodes of asymptomatic desaturations which were
self resolved. Patient was noted to occasionally have
desaturations into the mid 70s and 80%s, which were completely
asymptomatic aside from occasionally coughing. The likely
explanation for these episodes was mucus plugging versus poor
tracing on the sat monitor. These events self resolved without
concerning findings on Chest X-ray or ABG.
# Left hand swelling: Upper extremity arterial ultrasound was
negative. Patient had fair pulses and [**Last Name (un) 1106**] surgery was
consulted and did not recommend any intervention.
# Alcohol use: The pt endorsed significant alcohol use prior to
this hospitalization. He did not develop any signs of withdrawal
during this admission.
#####TRANSITIONAL#####
- Please increase diet as patient tolerates. He was able to
take PO while in the hospital
- Please titrate off oxygen to maintain oxygen saturations over
93%
- Please titrate off oxycodone as pain allows.
- We increased metoprolol to 75mg daily, and added amlodipine
5mg daily. If blood pressures are lower out of the hospital,
these medications can be down titrated and amlodipine can be
held
- INCIDENTAL findings on imaging that should be followed up:
hypodense liver lesion (too dense to be cyst) and bulky left
adrenal gland (will need MRI in non-emergent setting),
mediastinal lymphadenopathy: Incidentally noted on previous
imaging ([**6-/2161**]) felt to be reactive with multifocal pneumonia
and not pathological. Needs repeat chest CT for nodules in the
future.
Medications on Admission:
Nephrocaps Oral
metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB, wheeze.
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 disk* Refills:*2*
sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 caps* Refills:*2*
aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) inhaler Inhalation every 4-6 hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*3*
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation twice a day as needed
for shortness of breath or wheezing.
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Puff Inhalation twice a day.
7. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary: Decompensated acute systolic heart failure, end stage
renal disease, chronic obstructive pulmonary disease, acute
pancreatitis.
Secondary: Coronary artery disease, Hypertension, Dyslipidemia,
gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
It was our pleasure taking care of you at [**Hospital1 18**].
You were admitted for shortness of breath/ decompensated heart
failure.
While you were in the hospital, we found that your electrolytes
were abnormal, and there was a concern for a heart attack. We
performed a cardiac catheterization, looking at the vessels that
supply your heart and found no evidence of serious blockage and
no intervention was done. In addition, during your stay we
found that you had pancreatitis, an inflammation of one of the
organs deep in your belly which is painful.
We made the following changes to your medications:
START Amlodipine 5mg daily for high blood pressure
INCREASE Metoprolol to 75mg daily
START Oxycodone as needed for pain - this should be tapered off
with resolution of pain
Please keep the following appointments below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please continue dialysis at your regular Tuesday, Thursday,
Saturday schedule.
Please call your PCP to make an appointment for follow up within
one week of your discharge from rehab.
Department: ADVANCED VASC. CARE CNT
When: MONDAY [**2161-10-12**] at 1 PM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
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[
[]
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[
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[
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4473, 4808
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,615
| 169,784
|
20111
|
Discharge summary
|
report
|
Admission Date: [**2121-1-3**] Discharge Date: [**2121-1-17**]
Date of Birth: [**2074-3-9**] Sex: F
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old female
status post cadaveric renal transplant in [**2115**] for FSGS, who
has a history of diabetes mellitus and CHF, who presented to
[**Hospital3 **] on [**12-26**] with two days of exertional
dyspnea. She does have home oxygen requirements. She
started using 2 liters for symptomatic relief and she has a
cough productive of pink frothy sputum. At the time of that
presentation, she also was hyperglycemic as high as 792,
temperature of 101.2.
Her hospital course at [**Hospital1 487**] was notable for aggressive
diuresis. She had a broad infectious disease workup for
question of a right lower lobe pneumonia and had been on a
variable antibiotic region. Her initial workup was negative
for pulmonary embolism, so she was transferred to [**Hospital1 346**] on [**2120-12-26**] for further
workup.
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to FSGS status post
cadaveric renal transplant in [**2115**].
2. Diabetes mellitus. She is insulin dependent.
3. CHF. She has restrictive cardiomyopathy.
4. Hypertension.
5. Gout.
6. Osteoporosis.
7. Depression.
8. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Status post cadaveric renal transplant in [**2115**].
2. Status post open cholecystectomy.
SOCIAL HISTORY: She smokes half a pack of cigarettes per
day, occasional alcohol. By occupation she is a computer
programmer.
ALLERGIES: No known drug allergies.
MEDICATIONS UPON TRANSFER FROM OUTSIDE HOSPITAL:
1. Neoral 100 mg p.o. b.i.d.
2. Prednisone 20 mg p.o. q.d.
3. Lopressor 50 mg p.o. b.i.d.
4. Insulin NPH 30/70. Humalog sliding scale.
5. Protonix 40 mg p.o. q.d.
6. Zoloft 100 mg p.o. q.d.
7. Actigall 30 mg p.o. q.d.
8. Allopurinol 100 mg p.o. b.i.d.
9. Digoxin 0.125 mg p.o. q.d.
PHYSICAL EXAMINATION: Temperature 98.4, blood pressure
169/76, heart rate 82, respiratory rate 23. She is satting
90%. CVP was 20. Her initial ABG was pH 7.35, pCO2 of 34,
pO2 of 52, a bicarb of 20, and a base deficit of -5.
Generally she looked uncomfortable, but able to conduct a
conversation using accessory muscles. Head, eyes, ears,
nose, and throat: She had a slight proptosis on the right,
no thyromegaly, no cervical adenopathy. Chest is normal for
rales at the bases bilaterally. Heart was regular, rate, and
rhythm. Abdomen was soft and nontender. Her right lower
quadrant graft was nontender. Extremities were with some
bilateral leg edema. She had palpable DP and PT bilaterally.
LABORATORIES: White count 11.4, hematocrit 28.7, platelets
of 360. Sodium of 136, potassium 5.1, chloride of 105,
bicarb of 18, BUN of 59. Creatinine of 3.9. Glucose of 234.
Her AST was 12, ALT was 16. A sputum culture obtained on
[**12-27**] indicated 2+ gram-positive cocci, 1+
gram-positive rods, and 1+ gram-negative rods.
SUMMARY OF HOSPITAL COURSE: Patient is a 46-year-old female
with a history of diabetes mellitus and CHF as well as
hypertension, who was admitted from an outside hospital with
respiratory distress as well as renal failure. Her
creatinine was noted to be 3.9, which is elevated from a
baseline of 2.5. She appeared to be somewhat fluid
overloaded as well as having a component of pneumonia.
An echocardiogram was obtained to assess cardiac function.
Her ejection fraction was 55% with some dilatation in the
left atrium. Infectious Disease was consulted. She is
placed on a two week course of oxacillin and three week
course of levofloxacin. She was noted to have
methicillin-sensitive Staph aureus in her sputum. She
required intubation until adequate diuresis was achieved.
Cardiology was consulted to maximize cardiac function and to
evaluate this episode of mild pulmonary edema as well as
congestive heart failure.
After adequate volume status was achieved, patient was
eventually weaned off the vent and extubated. It was thought
that her renal failure was attributed to prerenal component
and perhaps a component of acute tubular necrosis. Her renal
function eventually resolved and returned back to baseline.
Oxygen requirements eventually were weaned. She was
eventually transferred to the floor. At that point, she was
requiring 5 liters of nasal cannula as well as BiPAP at
night. Physical Therapy evaluated the patient and
recommended that the patient be discharged home with a supply
of oxygen as well as outpatient pulmonary rehab in addition
of BiPAP at night.
At the time of discharge, she was tolerating a regular diet.
She functionally was improved, however, due to her
desaturation with increased activity, it was recommended by
Physical Therapy as well as Respiratory to continue with
oxygenation at home, to continue levofloxacin for another
additional week.
CONDITION ON DISCHARGE: Home with outpatient pulmonary
rehab.
DISCHARGE STATUS: Stable and guarded.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Pulmonary hypertension/congestive heart failure.
3. Respiratory distress.
4. Acute renal failure.
5. Status post cadaveric renal transplant in [**2115**].
6. Diabetes mellitus in [**2115**].
DISCHARGE MEDICATIONS:
1. Prednisone 10 mg p.o. q.d.
2. Sertraline 100 mg tablet one tablet p.o. q.d.
3. Tylenol 325 mg 1-2 tablets p.o. q.4-6h.
4. Metoprolol 12.5 mg p.o. b.i.d.
5. Percocet 1-2 tablets p.o. q.4-6h.
6. Saline spray [**2-8**] sprays q.i.d.
7. Neoral 50 mg p.o. b.i.d.
8. Lasix 60 mg p.o. b.i.d.
9. Bactrim SS one tablet 3x a week Monday, Wednesday, Friday.
10. Lorazepam 0.5-1 mg tablet p.o. q.h.s. prn insomnia.
11. Famotidine 20 mg one tablet p.o. b.i.d.
12. Patient is on an insulin scale that was provided by the
[**Hospital **] Clinic, it includes fixed doses as well as sliding
scales. This will be provided for the patient.
13. BiPAP at night; BiPAP ST [**1-11**] backup rate of 10 with a
bleed in of oxygen at 6 liters continuous. In addition, she
is to have pulmonary rehab.
14. Levofloxacin 250 mg p.o. q.d. for seven more days.
FOLLOW-UP PLANS: Patient is to followup with Dr. [**Last Name (STitle) 14252**] at
telephone number [**Telephone/Fax (1) 54103**] at the office in [**Location (un) 7661**]. She
was instructed to call to schedule an appointment for her
convenience. She additionally prefers to followup with her
own primary care physician for blood sugar control at the
[**Hospital **] Clinic. She is to continue with outpatient pulmonary
rehab, supply of oxygen.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 28937**]
MEDQUIST36
D: [**2121-1-17**] 16:21
T: [**2121-1-21**] 06:52
JOB#: [**Job Number 54104**]
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icd9cm
|
[
[
[]
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[
"96.04",
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icd9pcs
|
[
[
[]
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4984, 5193
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5216, 6051
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1330, 1425
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2993, 4859
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1948, 2964
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6069, 6774
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174, 1008
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1030, 1307
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1442, 1925
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4884, 4963
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,318
| 189,434
|
54075+59570
|
Discharge summary
|
report+addendum
|
Admission Date: [**2127-5-14**] Discharge Date: [**2127-5-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Inferior vena cava filter placement
History of Present Illness:
Ms. [**Known lastname 110842**] is a 86 y/o woman with PMH sig for osteoporosis, recent
C. diff infection, s/p ORIF in [**3-12**] by Dr. [**Last Name (STitle) **] and
subsequently transferred to [**Hospital 100**] Rehab who [**Street Address(1) 110843**]
House on [**5-14**] with difficulty breathing and O2 sat of 82% RA.
Afebrile per NH notes. She went to the ED where initial VS were:
99.1 110 132/80 22 99%4L, and was given Ceftriaxone, Vancomycin
for "pneumonia" on CXR. She had a LENI which showed extensive
right sided DVT, so she was started on heparin without a bolus
and admitted to the east medicine service.
On the floor, BNP was >40,000. CTA was done which showed
multiple bilateral pulmonary emboli and large effusions. She was
tachycardic on room air with stable blood pressure, but there
was concern for the possibility of decompensation so she was
transferred to the [**Hospital Unit Name 153**] for closer monitoring.
Per family members, reported worsening SOB over past couple
days, along with worseing LE swelling/declining MS. [**Name13 (STitle) **] daughter
says she is not independently mobile, can occasionally feed
herself, and will talk with them. On admission to the [**Hospital Unit Name 153**] she
was minimally verbal.
Pt was watched overnight in the [**Hospital Unit Name 153**] where she remained stable
on room air alternating with 2L NC. She remained tachycardic and
cards was consulted for concern of TWI's on ECG as well as
positive biomarkers. She was called out to the floor but the
hospitalists on the [**Hospital Ward Name **] requested that she be
transferred to a cardiology service.
Past Medical History:
1)Hip fracture s/p ORIF [**3-12**]
2)C. diff colitis--tx recently stopped [**5-7**]
3)Osteoporosis
4)Hypertension
5)Diverticulitis s/p L hemicolectomy in the early 80's at [**Hospital1 2025**].
6)Retinal disease/cataracts.
7)Rheumatoid arthritis
Social History:
No tobacco, EtOH, or IV drug use. Currently living at rehab.
Family History:
NC
Physical Exam:
vitals T AF BP 108/60 AR 93 RR 18 O2 sat 93% RA
Gen: Cachectic, laying in bed, soft voice
HEENT: MM slightly dry
Neck: JVP 10 cm
Lungs: +scattered crackles
Heart: RRR, nl s1/s2, no s3/s4, no m,r,g
Abdomen: Soft, NT/ND, +BS
Extrem: [**3-8**] bilateral edema (R>L), LLE colder than RLE
Neuro: Responsive to voice and commands
Pertinent Results:
Laboratory results:
[**2127-5-14**] 11:05AM BLOOD WBC-29.6*# RBC-3.36* Hgb-11.0* Hct-33.6*
MCV-100*# MCH-32.6* MCHC-32.6 RDW-17.6* Plt Ct-477*#
[**2127-5-14**] 11:05AM BLOOD PT-13.3* PTT-22.9 INR(PT)-1.2*
[**2127-5-14**] 11:05AM BLOOD Glucose-155* UreaN-22* Creat-0.5 Na-140
K-4.3 Cl-104 HCO3-25 AnGap-15
[**2127-5-14**] 11:05AM BLOOD CK(CPK)-31
[**2127-5-14**] 11:05AM BLOOD CK-MB-NotDone cTropnT-0.13* proBNP-[**Numeric Identifier 110844**]*
[**2127-5-14**] 09:07PM BLOOD CK-MB-3 cTropnT-0.09*
[**2127-5-15**] 04:44AM BLOOD Calcium-8.3* Phos-4.1# Mg-2.3
[**2127-5-18**] 10:25AM BLOOD CRP-40.0*
[**2127-5-22**] 04:40AM BLOOD WBC-15.4* RBC-3.53* Hgb-11.4* Hct-35.9*
MCV-102* MCH-32.4* MCHC-31.8 RDW-19.2* Plt Ct-691*
[**2127-5-22**] 04:40AM BLOOD PT-19.4* PTT-28.1 INR(PT)-1.8*
[**2127-5-22**] 04:40AM BLOOD Glucose-101 UreaN-17 Creat-0.5 Na-140
K-3.0* Cl-96 HCO3-36* AnGap-11
[**2127-5-22**] 04:40AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2
Relevant Imaging:
1)LE Doppler: 1. Acute deep venous thrombosis of the right
common femoral, superficial femoral, and popliteal veins. 2. No
evidence of DVT in the left lower extremity.
2)Cxray: Moderate/severe CHF
ECG: Sinus Tach @ 115, NL axis/intervals, no LVH, no s1q3t3 new
Q waves in V1/V2, TWI in precordial leads V1-V3 with TWF all
leads (Q and T wave changes new since [**3-/2127**])
3)Echo ([**2127-5-15**]): The left atrium is moderately dilated. There
is severe regional left ventricular systolic dysfunction with
septal akinesis, apical akinesis, lateral akinesis/hypokinesis.
Left ventricular systolic function is severely depressed.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] LVEF
20-25%. Right ventricular chamber size is normal. There is focal
hypokinesis of the apical free wall of the right ventricle. The
aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the report of
the prior study (images unavailable for review) of [**2122-4-13**]
left ventricular systolic function is now severely impaired.
Estimated pulmonary artery systolic pressure is now higher.
Mitral regurgitation and tricuspid regurgitation are now more
prominent.
Brief Hospital Course:
Ms. [**Known lastname 110842**] is 86 y/o female with PMH significant for recent ORIF,
recurrent C diff infections, now with CHF, PEs, leukocytosis,
and depressed mental status, transferred from [**Hospital Unit Name 153**] to [**Hospital1 1516**]:
1) Bilateral PE's: Likley from immobility after recent hip
surgery. Also explains EKG changes, elevated troponins, elevated
BNP, and initial hypoxia she presented with on admission. She
was started on heparin gtt with bridge to Coumadin. Cardiology
was consulted and felt that she would benefit from an IVC filter
given her burden of PE and ECHO findings. She underwent IVC
filter placement with no complications. She was restarted on
heparin gtt and Coumadin but given difficult blood draws heparin
was changed to Lovenox. Lovenox should be stopped once INR>2.0.
INR at discharge was 1.8.
2) CHF: No known history of CHF. Likely secondary to high
burdern of PE. Cardiac enzymes elevated in setting of PE.
Cardiology team was consulted and recommended medical management
of heart failure including beta-blocker, ace-inhibitor, and
diuresis with Lasix. She diuresed appropriately and tolerated
medications well. She will be discharged on fixed dose of Lasix
with close monitoring of her I/O's. If there is >3 lb weight
gain, she should receive an additional dose of Lasix. She is
also being discharged on supplemental potassium since she is
being diuresed. Her potassium levels should be monitored
closely.
3) Leukocytosis: Patient presented with leukocytosis ~30 on
admission. Unclear etiology. All culture data were negative. C.
diff negative x3; checked given recent history of infection. She
was empirically started on Flagyl, which she should take for
total of 2 weeks until B toxin result returns. Likely elevated
in context of PE and slowly coming down; ~15 at time of
discharge.
5) s/p hip replacement: Physical therapy worked closely with
patient. Scheduled for follow-up with Dr. [**Last Name (STitle) **] in few weeks.
6) dementia: Ms. [**Known lastname 110842**] appears to have dementia, corroborated
with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] over the last couple years. This was
addressed with the family in multiple family meetings with
social work, specifically regarding her health care proxy who is
primarilly her brother. Secondary HCP is her daughter.
Medications on Admission:
Medications on Admission:
Lopressor 12.5 mg [**Hospital1 **]
Ca Carb
Vit D
Colace
Vicodin
Flagyl 250 mg po TID (stopped [**5-7**])
Vancomycin 250 mg TID (started [**5-7**])
Medications on transfer:
Asprin 325mg daily
Captopril 6.25mg po tid
Heparin gtt
Flagyl 500mg po tid (IV as backup if not taking po's)
Metoprolol 12.5mg po bid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 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. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
8. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) micrograms
Subcutaneous Q12H (every 12 hours): please stop once INR>2.0.
9. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day: please stop taking on [**2127-5-28**].
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Extended Care
Facility:
Park Place - [**Street Address(1) **]
Discharge Diagnosis:
1)Pulmonary embolism
2)Congestive heart failure
3)Deep venous thrombosis
Discharge Condition:
Stable
Discharge Instructions:
1)Please take all medications as listed in the discharge
instructions. A few changes have been made.
2)You have been started on a medication called Lovenox and
Coumadin since you were found to have a clot in your leg and
lungs. These medications will help thin your blood to prevent
any further clots forming. You also had an IVC filter placed to
prevent further clots.
You will need close monitoring of your INR. Once your INR>2.0
the Lovenox can be stopped.
3)You are also being discharged on a medication called Flagyl to
treat your diarrhea, which was thought to be due to an
infection. Please take this medication for the next 10 days. You
will complete the course on [**5-28**].
4)You are being discharged on potassium supplements since your
potassium was low throughout most of your hospital stay. Please
have your potassium checked routinely with appropriate
supplementation.
5)Please schedule follow-up with your primary care physician
within the next 1-2 weeks. Please attend all appointments as
listed below.
6)If you experience any fevers, chills, chest pain, SOB,
dizziness, abdominal pain or any other concerning symptoms
please return to the emergency room.
Followup Instructions:
1)Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2127-6-12**] 10:20
2)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2127-6-19**] 10:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Name: [**Known lastname 18162**],[**Known firstname 3863**] Unit No: [**Numeric Identifier 18163**]
Admission Date: [**2127-5-14**] Discharge Date: [**2127-5-23**]
Date of Birth: [**2040-10-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1305**]
Addendum:
On the morning of discharge, INR 2.1 and Lovenox injections were
discontinued. Ms. [**Known lastname **] was discharged on coumadin only as
longterm anticoagulation therapy.
Discharge Disposition:
Extended Care
Facility:
Park Place - [**Street Address(1) **]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1307**]
Completed by:[**2127-5-23**]
|
[
"707.03",
"428.20",
"401.9",
"428.0",
"288.60",
"453.41",
"415.19",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
11408, 11623
|
5306, 7664
|
269, 307
|
9154, 9163
|
2694, 3630
|
10389, 11385
|
2330, 2334
|
8047, 8950
|
9058, 9133
|
7716, 7864
|
9187, 10366
|
2349, 2675
|
222, 231
|
3648, 5283
|
335, 1965
|
7889, 8024
|
1987, 2235
|
2251, 2314
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,069
| 104,665
|
7786
|
Discharge summary
|
report
|
Admission Date: [**2134-8-12**] Discharge Date: [**2134-8-19**]
Date of Birth: [**2053-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p fall- SAH, L acetabular fx, L2+L3 transverse process
fractures, question of T and L spine compression fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 year-old man with history of CAD s/p IMI, afib s/p pacemaker
on coumadin, COPD, laryngeal CA, who was admitted to the TICU
with SAH after a fall, and is now transferred to the MICU for
management of respiratory failure. Briefly, he had a mechanical
fall on [**2134-8-12**] and subsequently sustained a SAH, transverse
process fracture at L2/L3, a compression fracture of
T3/T12/L1/L4, and a left acetabular fracture. His SAH and
fractures were thought to be non-operable per neurosurgery and
ortho, respectively. His course in the TICU was also remarkable
for respiratory distress and ?new hypoxia on the day after
admission (he was 98%2L on the day of admission per review of
the notes), for which he was placed on a face mask, started on
solumedrol, nebs, and azithromycin empirically for a presumed
COPD exacerbation. This was weaned down to 2L NC on the day
prior to transfer and he was satting 98%ra on the morning of
transfer with a plan to go to rehab today.
.
Per report, later this morning around 11 a.m., he was found to
be dyspneic, lethargic and breathing at a rate of 40. He was
placed on a nonrebreather and had O2 satts in the 70s, HR 100s
(afib), SBP 110. ABG was 7.37/47/98/28. He was thought to have
aspirated vs flash pulmonary edema and given lasix 40 mg IV x 1
with good UOP. Of note, his family has been updated and he
agrees to BiPAP but would want to be comfortable if this fails
(after many conversations with patient and family).
.
His hospital course has also been remarkable for delerium
thought to be secondary to sundowning and narcotics, with
geriatrics consulted.
Past Medical History:
AAA repair 4 years earlier
Thyroidectomy 3 years earlier
Advanced COPD
AFib treated with coumadin
CAD and pacemaker placement
Social History:
Lives at home with son. [**Name (NI) **] current alcohol or tobacco use.
Family History:
Unknown
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
.
[**2134-8-12**] 06:05AM BLOOD WBC-17.9*# RBC-5.01# Hgb-14.6# Hct-44.8#
MCV-89 MCH-29.1 MCHC-32.6 RDW-14.1 Plt Ct-200
[**2134-8-12**] 06:05AM BLOOD Neuts-93.8* Lymphs-3.5* Monos-2.5 Eos-0.1
Baso-0.1
[**2134-8-12**] 06:05AM BLOOD PT-32.5* PTT-35.3* INR(PT)-3.3*
[**2134-8-12**] 06:05AM BLOOD Glucose-150* UreaN-24* Creat-1.8* Na-137
K-4.8 Cl-102 HCO3-25 AnGap-15
[**2134-8-12**] 06:05AM BLOOD CK(CPK)-88
[**2134-8-12**] 06:05AM BLOOD CK-MB-NotDone
[**2134-8-12**] 06:05AM BLOOD cTropnT-<0.01
[**2134-8-12**] 09:01AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
[**2134-8-12**] 06:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2134-8-12**] 04:14PM BLOOD Type-ART pO2-43* pCO2-35 pH-7.44
calTCO2-25 Base XS-0
[**2134-8-12**] 06:17AM BLOOD Lactate-1.6
[**2134-8-12**] 04:14PM BLOOD freeCa-1.12
.
.
PERTINENT STUDIES:
.
CT Chest ([**8-12**]):1. Multiple thoracolumbar compression deformities
as described above. 2. Right transverse process fracture of L3
and L4. 3. Emphysema and multiple pulmonary nodules, one of
which is not included in the field of view of the prior
examination, measuring 4 mm. Given risk
factors, a 12-month followup is recommended. 4. Multiple
hepatic cysts. 5. Bilateral renal cysts
CT Head ([**8-12**]):There is asymmetric dense appearance of the right
side of the tentorium and
lateral to it indicating a possible suddural hemorrhage
associated. Close f/u to assess the stability of the above
findings is recommended.
CT C-Spine ([**8-12**]):There is asymmetry in the size of the disc
space at C4/5, wider anteriorly.
(series 400b, im 19). Though this can relate to DJD and disc
bulge, ligamentous injury needs to be excluded given the history
of trauma and no prior studies. MR c spine can be performed for
the same.
LENI ([**8-18**]): LLE: partially occluded clot in greater saphenous,
unchanged from prior; superficial femoral vein proximal
thrombus. Possible thrombus . RLE: interval development of
partially occlusive clot in greater saphenous at junction of
common femoral.
CT Head ([**8-18**]): 1. No evidence of new hemorrhage 2. Stable
appearance of bilateral subdural hemorrhage layering along the
tentorium cerebelli. Interval resolution of subarachnoid
hemorrhage seen in the interpeduncular cistern. 3. Chronic
small vessel ischemic changes.
4. Prominent ventricles and sulci, unchanged.
TTE ([**8-18**]): Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate pulmonary hypertension.
Brief Hospital Course:
Patient was admitted to T/SICU from ER for management of his
injuries s/p mechanical fall, which included SAH, L acetabular
fracture, L2L3 transverse process fractures, and thoracolumbar
compression injuries. Orthopaedics and Neurosurgery were
consulted for these injuries. Orthopaedics recommended
non-operative management of L hip fracture. Patient was to be
touch-down weight-bearing for 6 weeks and to follow-up in the
[**Hospital 13308**] clinic after this course of time. Neurosurgery
recommended normalization of his INR and repeat imaging of his
head in 6hours and 24 hours. No intervention was recommended
for vertebral fractures. His repeat head CTs revealed no
change.
Patient had unstable respiratory status while in the ICU, which
was felt to be d/t COPD flair. He was treated with steroids,
CPAP or BiPAP, and Azithromycin. He experienced some delirium
and sundowning in the unit and geriatrics was consulted and
recommended afternoon haldol rather than standing doses and
tylenol with breakthrough oxycodone rather than morphine
standing.
On HD4 patient had discussion with team regaring desire to be
DNR/DNI and desire for care not to be escalated. Patient was
weaned to 2L NC and transferred to floor. Physical therapy and
occupational therapy evaluated the patient and hospice care was
consulted. Patient had a speech and swallow consult. 1:1
supervision with crushed/pureed foods was recommended.
On HD5 patient became increasingly tachypneic and was
transferred back to the T/SICU for BiPAP. The decision was made
to transfer patient from surgical intensive care unit to medical
intensive care unit.
During his MICU stay, the patient was placed on Bipap for
hypoxic respiratory failure. He was placed empirically on
antibiotics and was given IV steroids for a possible COPD
exacerbation. He remained dyspneic with labored work of
breathing while on Bipap. LENIs were performed, which showed a
new DVT in his lower extremity. He was thus placed on a heparin
drip. He went into AFib with RVR and was started on a diltiazem
drip. He developed increased work of breathing in the setting
of AFib with RVR and eventually expired from cardiopulmonary
arrest.
Medications on Admission:
Nitropatch 0.2 mg per hour
folic acid 1 mg per day
Toprol-XL 12.5 mg per day
Protonix 40 mg per day
Coumadin 2mg per day
Mirtazapine
Levoxyl 50 mcg per day
Testosterone
Vytorin 20/10,
Albuterol inhaler
Combivent inhaler
Fluticasone inhaler
Calcium/vit B-12
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-8**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-12**]
hours as needed for pain.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p Fall
Subarachnoid hemorrhage
Transverse process fractures L2,3
Compression fracture T3,12; L1,4
Left acetabular fracture
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2134-11-29**]
|
[
"852.00",
"V45.01",
"584.9",
"805.2",
"585.9",
"518.5",
"276.52",
"292.81",
"427.31",
"491.21",
"E935.8",
"403.90",
"808.0",
"V10.21",
"272.4",
"V66.7",
"530.81",
"412",
"805.4",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8711, 8720
|
5428, 7624
|
431, 438
|
8889, 8898
|
2860, 2860
|
8954, 8993
|
2322, 2331
|
7931, 8688
|
8741, 8868
|
7650, 7908
|
8922, 8931
|
2346, 2841
|
276, 393
|
466, 2066
|
2876, 5405
|
2088, 2215
|
2231, 2306
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,291
| 106,237
|
31106
|
Discharge summary
|
report
|
Admission Date: [**2132-12-9**] Discharge Date: [**2132-12-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Hypoxemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname **] is an 86 yo woman with 3V CAD s/p MI and multiple
coronary interventions, DM2, HTN, dementia and a h/o DVT who
presents from her nursing home with hypoxemia.
.
She had reportedly had symptoms c/w an upper respiratory tract
infection for a week prior to desaturating to the high 70s on 2
LNC. Her O2 sat improved to the 90s with 5L by NC. At the time,
she was normotensive, but tachycardic to the 140s and tachypneic
to the 40s.
.
In the ED, her initial VSs were 99.8, 120, 73/58, 18, 97% 5LNC.
She spiked a temp to 101.4. A CXR was suggestive of pulmonary
edema and possible RLL pneumonia. Her blood pressure remained
low despite 1500 cc NS. She was given levofloxacin 750 mg PO x1,
vancomycin 1 g IV x1. A central line was inserted, and she was
transferred to the [**Hospital Unit Name 153**] for further management.
.
The pt is mildly demented, and had a difficult time presenting
any further history. She reports rhinorrhea and sinus congestion
and does report a cough currently that is nonproductive. She
denies chest pain, difficulty breathing, changes in bowel
habits. She denies leg swelling or calf pain.
.
She received the influenze vaccine about 2 weeks ago, she
reports. She received the Pneumovax in [**8-9**].
Past Medical History:
PMH:
Past Medical History:
# CAD (anteroseptal MI [**12-7**], inferior MI (old - 20yrs ago); LAD
STEMI [**6-8**] c/b post-stent dissection and in-stent thrombosis
requiring urgent PCI
# Recent C-diff colitis following antibiotic treatment for UTI
# RLE DVT [**10-7**]
# Depression
# GERD
# Glaucoma
# Asthma
# Facial droop (old per daughter)
# Claustrophobia
# diabetes mellitus, type 2
# Hypertension
.
Social History:
Social history is significant for the absence of current tobacco
use, former tobacco user. There is no history of alcohol abuse.
The patient lives at [**Hospital1 599**].
Family History:
Non contributory
.
Physical Exam:
Vitals: T: 97.3 BP: 96/56 P: 100 R: 24 SaO2: 100% 4LNC
General: Awake, alert, NAD, pleasant, appropriate, cooperative
HEENT: EOMI, no scleral icterus, MMM, no lesions noted in OP
Neck: no cervical LAD, JVP not visible while upright
Pulmonary: Lungs with rales bilaterally, decreased breath sounds
at R base, no wheezes or ronchi
Cardiac: borderline tachy, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, 1+ DP pulses b/l
Skin: no rashes or lesions noted.
Pertinent Results:
LABS ON ADMISSION
[**2132-12-9**] 04:30AM WBC-11.5*# RBC-4.53 HGB-12.2 HCT-37.6 MCV-83
MCH-27.0 MCHC-32.5 RDW-16.1*
[**2132-12-9**] 04:30AM NEUTS-91.6* LYMPHS-5.7* MONOS-2.3 EOS-0.1
BASOS-0.2
[**2132-12-9**] 04:30AM PLT COUNT-293
[**2132-12-9**] 04:30AM GLUCOSE-270* UREA N-24* CREAT-1.1 SODIUM-143
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-31 ANION GAP-16
[**2132-12-9**] 04:40AM LACTATE-2.3*
[**2132-12-9**] 09:49AM LACTATE-1.4
[**2132-12-9**] 09:49AM TYPE-[**Last Name (un) **] PO2-47* PCO2-56* PH-7.38 TOTAL
CO2-34* BASE XS-5 COMMENTS-GREEN TOP
STUDIES
Port CXR [**12-9**] - Mild to moderate pulmonary edema with a small
right effusion likely secondary to heart failure. More confluent
opacity in the right lung base may represent confluent edema
although underlying pneumonia cannot be excluded. Repeat
radiographs following diuresis recommended.
TTE [**12-10**] - EF 25%, The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe regional left ventricular systolic
dysfunction with mild aneurysm of the basal inferior wall and
apex and near akinesis of the inferior wall, and distal half of
the anterior septum and anterior wall, apex and distal lateral
wall. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
is normal with focal hypokinesis of the apical free wall. 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. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2132-9-2**],
the distal half of the anterior septum and anterior wall, apex,
and distal inferior wall dysfunction is new c/w interim ischemia
(mid-LAD distribution) with underlying multivessel CAD. Moderate
pulmonary artery systolic hypertension and increased LVEDP are
now identified.
Chest Xray [**2132-12-14**]- New left lower lobe infiltrate, reduction in
size of right effusion.
Port CXR [**12-15**] - This is compared with the prior from [**2132-12-14**]. The NG tube is in the proximal stomach. There is minimal
interval change in the pleural effusions bilaterally. The
pulmonary edema is somewhat improved. There is interval removal
of the right subclavian line.
IMPRESSION: NG tube in standard position. Improvement in
pulmonary edema, effusion unchanged.
LABS ON DISCHARGE
[**2132-12-17**] 04:18AM BLOOD WBC-9.9 RBC-3.77* Hgb-9.8* Hct-30.7*
MCV-82 MCH-26.0* MCHC-31.9 RDW-15.7* Plt Ct-368
[**2132-12-17**] 04:18AM BLOOD Glucose-132* UreaN-18 Creat-0.9 Na-146*
K-3.8 Cl-99 HCO3-38* AnGap-13
[**2132-12-15**] 08:33PM BLOOD CK-MB-4 cTropnT-0.56*
[**2132-12-15**] 08:33PM BLOOD CK(CPK)-50
[**2132-12-17**] 04:18AM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.5 Mg-2.0
[**2132-12-15**] 08:33PM BLOOD Vanco-25.0*
[**2132-12-15**] 06:28PM BLOOD Type-ART pO2-239* pCO2-71* pH-7.40
calTCO2-46* Base XS-15
Brief Hospital Course:
ASSESSMENT/Plan: 86 yo woman with 3V CAD, DM2, HTN, dementia
presents with respiratory distress, fever, SIRS likely [**1-3**]
pneumonia with course c/b pulmonary edema, and elevated cardiac
enzymes likely [**1-3**] demand ischemia.
1) Respiratory distress/hypoxia: Initially admitted withHad
episodes of transient desaturation, but appeared asymptomatic
overnight on the day of presentation. This was likely due to
pulmonary edema, CHF, and pneumonia. The patient was initially
treated broadly with vancomycin and zosyn which was changed to
vancomycin and levaquin, of which a 7 day course was completed.
The patient was ruled out for influenza and all blood cultures
were no growth. She was diuresed with IV lasix successfully with
improvement in her respiratory status. At the time of discharge,
the patient was sating 94-98% on 2 L NC and was no longer
tachypneic.
2) Systolic Heart failure/CAD - The patient was noted to have
new dysfunction of anterior septum and inferior wall as well as
new aneurysmal dilation, which was new compared to a prior TTE
from [**9-8**]. This was felt to be secondary to interval stent
closure. EKGs did show non-specific inverted T waves
precordially which were concnering for ongoing ischemia in the
setting of volume overload. Cardiac enzymes were checked and
were significant for troponin-T 0.42, CK 134, CK-MB 18, and MB
index 13.4. Cardiology was consulted who felt that her symptoms
of nausea, diaphoresis, and elevated cardiac enzymes were likely
due to demand ischemia rather than ACS. A heparin gtt was not
started to due unlikely ACS and the patient was not sent to the
cardiac cath lab as her enzymes began to trend down rapidly in
the setting of decreased symptoms and hemodynamic stability. She
was continued on aspirin, plavix, simvastatin, and metoprolol
and she was started on lisinopril, which was gradually titrated
up during the course of hospitalization. She was discharged on
lisinopril 5mg po daily with goal of eventually uptitrating to
10mg daily. In addition, she should be changed to long acting
beta-blocker such as toprol xl as soon as her volume status is
stabilized. Her home dose of lasix 20mg daily was also
restarted and she should be followed closely with daily weights.
Dry weight on discharge is 55.1kg. She should follow a low
sodium diet.
3)DM2 - Held po hypoglycemics and placed on ISS. Started on
ACE-I as above. She usually takes glyburide 5mg daily. This
was not restarted on discharge as she was not taking regular po
intake.
4) Anxiety - Takes ativan prn for baseline anxiety, which was
used carefully in the setting of tenous mental status in setting
of infection and demand ischemia. Three days prior to discharge
ativan was stopped completely and held for the remainder of her
hospital stay due to concern for contribution to altered mental
status.
5) Depression - She was continued on her outpatietn regimen of
paroxetine and olanzapine qhs.
6) Glaucoma - Continued eye drops.
7) Nutrition: At the time of discharge pt was not taking in
adequate POs. An NG tube was placed. Tube feed were not
started given plan for transfer within several hours of
placement, however goal is for her to be started on tube feeds
at [**Hospital 100**] Rehab MACU. She was given 250cc free water bolus for
hypernatremia prior to transfer.
8)Electrolytes - She will require daily chem 7 check and likely
daily repletion of K, with goal K 4-4.5.
9)Code status - DNR/DNI, discussed with family
Medications on Admission:
Aspirin 325 mg
Clopidogrel 75 mg
Lisinopril 5 mg
Metoprolol Tartrate 37.5 tid
Simvastatin 80 mg
Glyburide 5 mg
Furosemide 40 mg
Paroxetine HCl 30 mg
Olanzapine 2.5 mg qhs
Pantoprazole 40 mg
Docusate Sodium 100 mg [**Hospital1 **]
Prednisolone Acetate 1 % Drops [**Hospital1 **]
Naphazoline-Pheniramine 0.025-0.3 % Drops qid
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-3**] PO BID (2 times a
day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop
Ophthalmic QID (4 times a day).
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): See insulin Sliding Scale.
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-11**]
MLs PO Q6H (every 6 hours) as needed for cough.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: Respiratory distress due to congestive heart
failure and pneumonia
Secondary Diagnosis:
# CAD (anteroseptal MI [**12-7**], inferior MI (old - 20yrs ago); LAD
STEMI [**6-8**] c/b post-stent dissection and in-stent thrombosis
requiring urgent PCI
# Recent C-diff colitis following antibiotic treatment for UTI
# RLE DVT [**10-7**]
# Depression
# GERD
# Glaucoma
# Asthma
# Facial droop (old per daughter)
# Claustrophobia
# diabetes mellitus, type 2
# Hypertension
Discharge Condition:
At the time of discharge, the patient was sating 94-98% on 2
Liters Nasal Cannula and was no longer tachypneic
Discharge Instructions:
You were admitted to the hosptial with low oxygen levels. This
was due to a combination of pneumonia and congestive heart
failure. You were treated for pneumonia with antibiotics, which
you completed while in the hosptial. You where treated for the
congestive heart failure with diuretics.
.
You are to eat a low salt diet.
.
Check you weight daily. At the hospital, your weight was 55.1
kg. This is a good weight for you. If you weight starts to
increase it may indicate that your heart is not working as well
as it should and you should call the cardioulgy office at
[**Telephone/Fax (1) 5003**].
.
If you have any symptoms of shortness of breath, chest pain,
fevers, cough, or any other concerning symptoms you should come
to the hospital immediately
.
Please take all of your medications as prescribed.
.
Please keep all of your appointments as scheduled.
Followup Instructions:
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (PRE) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2133-1-9**] 9:00
|
[
"276.4",
"486",
"V12.59",
"458.9",
"428.0",
"414.01",
"437.0",
"365.9",
"427.1",
"276.0",
"401.9",
"285.9",
"493.90",
"290.40",
"530.81",
"799.02",
"790.5",
"428.22",
"412",
"250.00",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11460, 11526
|
6028, 9505
|
273, 280
|
12052, 12165
|
2824, 6005
|
13079, 13252
|
2195, 2216
|
9880, 11437
|
11547, 11547
|
9531, 9857
|
12189, 13056
|
2231, 2805
|
224, 235
|
308, 1560
|
11654, 12031
|
11566, 11633
|
1609, 1988
|
2004, 2179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,618
| 187,332
|
21175
|
Discharge summary
|
report
|
Admission Date: [**2196-3-29**] Discharge Date: [**2196-4-1**]
Date of Birth: [**2173-6-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
22 yo male, h/o primitive neuroectodermal tumor with mets to
brain and spine, transferred from [**Hospital1 1926**], initially in MICU
and then transferred to the floor. He was initially diagnosed
with a thoracic gangliogliom /resected in [**2194**]. He had back
pain in [**2-26**], seen at [**Company 2860**], and was found to have mets to brain
and spine. Biopsy at that time confirmed diagnosis of NET. At
this time, he had radiation to his spine (3600 cGy) with
carboplatin as sensitizer. He then had 6 cycles of
cytoxan/vincristine as maintenance, followed by high dose chemo
and stem cell tx 3 months ago. MRI 3 months after this ([**2196-2-23**])
showed some enhancement along spine at C2, mid thoracic, and
sacral lesion, consistent with metastatic disease. MRI brain
was neg for disease, and cytology on LP was negative. He
started temozolomide/oral etoposided [**2196-3-14**]. Most recent MRI
showed new left frontal lobe lesion among other mets.
Most recently, he has been on multiple meds for pain, including
Dilaudid, methadone, and he had recently had an increase in his
decadron. Thalidomide had also recently been started. The
weekend prior to admission, he had intermittent episodes of
somnolence interrupted by completely lucid/alert moments. On
morning of admission, he was slurring speech, making grammatical
errors. He had a CT at [**Hospital3 **] (thought to have
stable appearance). His mental status partially improved after
administration of Narcan. He was transferred to [**Hospital1 18**] MICU for
an ICU bed.
In the MICU, his mental status continued to improve. He was
followed by neurology/neurosurgery. Antibiotics were initially
administered for ?meningitis (LP not performed), and it was felt
that no emergent treatment was needed at this time. Upon
transfer to the floor, his mental status was improved but still
not at baseline; he was still somnolent, drowsy, but with no new
weakness, tingling, neurologic deficits. He denies
fevers/chills/stiff neck/photophobia/new urinary or bowel
symptoms. Plan is for transfer to [**Hospital1 **] if ICU bed is
available vs. discharge home.
Past Medical History:
1. Thoracic Spine Ganglioma resected [**2194**]
2. Primitive Neuroectodermal tumor with mets to brain and
spine, dx [**2-26**], s/p radiation, chemo; currently was on
thalidomide; most recently on temozolomide/oral etoposide.
Social History:
Lives with parents
Denies smoking, etoh, drugs
Family History:
NC
Physical Exam:
VS: afeb, 98/56 70 18
Gen: thin male, ill-appearing, lying in bed, very pleasant
HEENT: Pupils reactive, right larger than left, OP clear, no
rashes/sores
Neck: no LAD, no bruits appreciated, no JVD
CV: 2/6 SEM LLSB, no r/g; with port in left SC; no
erythema/tenderness
Lungs: CTA bilaterally, no w/r/r
Abd: soft, nt/nd, nabs, no masses appreciated
Extr: no c/c/e, PT 1+ bilaterally
Neuro: slight abduction of right eye, with some facial asymmetry
with droop on right; UE strenght [**5-26**] bilaterally and
symmetrically, LE 3/5 strength, decreased sensation to light
touch in LE bilaterally; no pronator drift
Pertinent Results:
Labs:
BLOOD WBC-1.4* RBC-2.33*# Hgb-7.7* Hct-21.2* MCV-91 Plt Ct-35*
ANC=850*
Glucose-248* UreaN-8 Creat-0.6 Na-135 K-3.4 Cl-97 HCO3-34*
AnGap-7*
Calcium-8.7 Phos-2.9 Mg-1.8
MRI brain:
Largest lesion in Left frontal lobe abutting frontal [**Doctor Last Name 534**], small
amount intraventricular blood in horns of lateral ventricls,
small lesions in right frontal and left cerebellar
Brief Hospital Course:
1. Delta MS: was likely in setting of oversedation from
medications. He was on dilaudid, methadone, and had recently
been started on thalidomide (which can cause somnolence). His
mental status improved after Narcan, was started empirically on
broad spectrum antibiotics for ?meningitis; these were stopped,
however, as he has no obvious signs of meningitis. LP was
deferred given thrombocytopenia. His mental status remained
stable (although not at baseline according to family). All
sedating meds continued to be held, and he was discharged just
on dilaudid for pain control. He will follow up with his
primary oncologist at [**Hospital3 28900**] who will arrange for
further pain management and treatment.
2. Neuroectodermal tumor: seen by neuro, neuroonc in-house; no
treatment at this time. As per his primary oncologist, will
either be transferred back to [**Hospital1 1926**] or home tomorrow. No
worsening on MRI, no herniation or midline shift. He had visual
field cuts that were possibly new, but his neurologic exam
remained stable while in-house. Decadron was continued for
possible cerebral edema. His oncologist at [**Hospital1 1926**] (Dr. [**First Name (STitle) **]
will follow up with him after discharge for further management.
He will have also have ophthalmology follow up for formal visual
field testing and management.
3. Pancytopenia: likely related to chemotherapy, received 1 U
PRBC in MICU, no signs of active bleeding. His ANC was 540 at
time of discharge, and platelets/hematocrit were stably low. He
was kept on neutropenic precautions while in-house.
4. Pain: dilaudid as needed for pain, and he was discharged on
this medication. He will follow up in the pain clinic at
[**Hospital3 1810**] so that a better pain regimen can be
determined (and oversedation can be avoided).
5. Constipation: His aggressive outpatient bowel regimen was
continued.
6. Bladder function: Detrol was continued in-house.
7. Dispo: He was discharged to home, to continue on Dilaudid
for pain control. He will follow up in 2 days at [**Hospital1 **] for
further management.
Medications on Admission:
Methadone 10 mg daily
Dilaudid 4 mg prn
Xanaflex 4 mg
Decadron 2 mg TID
Amitryptilline 25-50 mg qhs
Protonix 40 mg daily
Detrol 1 mg [**Hospital1 **]
Senna
Zofran
Thalidomide 50 mg qhs
Fiber laxative
ALL: NKDA
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
6. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**4-27**]
hours as needed for 4 days: Please do not take if somnolent or
oversedated.
Disp:*32 Tablet(s)* Refills:*0*
7. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1)
Packet PO qhs () as needed for constipation.
8. Tolterodine Tartrate 1 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Primitive Neuroectodermal Tumor
2. Somnolence/oversedation
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all your medications exactly as described in
this discharge paperwork.
2. Please follow up with your neuro-oncologist, Dr. [**First Name (STitle) **], as
described below.
3. Please call your doctor if you are experiencing fever,
chills, chest pain, shortness of breath, increased weakness, or
with any other concerns.
Followup Instructions:
1. Please follow up on Monday with Dr. [**First Name (STitle) **] at [**Hospital1 11900**]. She will arrange for you to follow up in the Pain
Clinic at [**Hospital3 1810**]. She will also arrange for you to
follow up in the ophthalmology clinic for evaluation and formal
visual field testing.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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icd9cm
|
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[
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[
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323, 329
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7298, 7306
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3482, 3871
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6027, 6240
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80,759
| 101,637
|
53719
|
Discharge summary
|
report
|
Admission Date: [**2102-3-21**] Discharge Date: [**2102-3-28**]
Date of Birth: [**2036-3-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Medicine Admission Note
CC: Abdominal pain
HPI: Ms. [**Known lastname **] is a 66 yo woman with history of
hypertension, possible CKD, prior CCY ([**2089**]), here from [**Hospital1 5979**] with pancreatits, after she presented there with
abdominal pain. She in fact developed abdominal pain 10 days
ago, on good [**Hospital1 2974**], and presented to LGH. She was discharged
from the ED. She was called back for possible pulmonary edema,
and to rule out MI, which was negative.
After discharge, she continued to have abdominal pain, with
nausea and anorexia. The pain has been constant, throughout her
entire abdomen, and radiating to her back. The pain was not
relieved by tylenol. She has had shortness of breath with the
pain. She had dark urine, but no changes in her stool. She has
not had fevers, but has had chills.
Prior to the onset of pain, she had been taking protein shakes,
substituting for one meal a day, for weight loss. She lost 7
lbs.
She has intermittent headaches. She denies any other urinary
symptoms, rashes, diarrhea, masses or lesions. ROS otherwise
reviewed in 13 systems and negative.
Past Medical History:
PMH
Hypertension, poorly controlled
?Hyperlipidemia
?CKD
Prior CCY, [**2089**]
Prior hysterectomy, for benign mass
Prior abnormal pap smears
Social History:
SH:
Originally from [**Male First Name (un) 1056**]. Works as secretary. No alcohol or
tobacco. Married, 2 children, grown, one grandchild.
Family History:
FH: Mother died in early 80s, "old age", father still alive,
age [**Age over 90 **], just diagnosed with cancer.
Physical Exam:
Physical exam
Vital signs: Tmax 98.0 BP 148/78 HR 60 16 91% RA O2 sat
General: in NAD, obese
HEENT: Faint scleral icterus, OP moist, no LAD, JVP difficult to
see.
Lungs: decreased at bases, no rales, no wheezes with forced
expiration.
CV: RRR without murmurs
Abdomen: soft, tender in epigastrium, and throughout upper
abdomen, no rebound or guarding. Nondistended, bowel sounds
present.
Ext: no edema
Neuro: alert/oriented X3, face symmetric, answers all questions
appropriately, full strength in upper and lower extremities.
Sensation normal.
Pertinent Results:
Relevant data:
Labs [**3-21**]
139 105 11 119 AGap=15
-------------
3.7 23 1.0
Trop-T: <0.01
Ca: 8.7 Mg: 1.9 P: 3.1
ALT: 803 AP: 329 Tbili: 4.1 Alb: 3.8
AST: 628
Lip: 8590
wbc 6.4 hgb 12.0 hct 38.1 plts 259
N:81.1 L:15.5 M:2.8 E:0.4 Bas:0.2
PT: 11.6 PTT: 27.8 INR: 1.1
UA with trace ketones, trace protein, 1 wbc, 1 rbc
urine culture pending
RUQUS [**Hospital1 18**] [**3-21**]:
IMPRESSION:
1. Status post cholecystectomy with common bile duct dilatation
to 13 mm, but no intrahepatic biliary duct dilatation. No stones
are seem in the visualized portions of the common bile duct,
though the distal duct is not well evaluated. MRCP is a more
sensitive exam for the detection of choledocholithiasis and can
be performed for further evaluation.
2. Echogenic liver consistent with fatty infiltration of the
liver. More severe hepatic disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on the basis of this study
EKG [**3-21**] SB nl axis, intervals, no ischemic changes.
Labs at LGH [**3-21**]:
Cr 1.04
Alk phos 372
Bili 5.4
AST 732
alt 911
Lipase 6741
CT from LGH, dissection protocol: No dissection, found to have
acute pancreatitis, without pseudocyst or abscess. Small 5 mm
increased density in the region of the pancreatic head/distal
CBD could be an obstructing stone/choledocholithiasis.
ERCP REPORT: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
A single stone was extracted successfully using a balloon. Two
more balloon sweeps were performed that did not reveal
additional stones or sludge.
Impression: The ampulla appeared bulging concerning for an
impacted stone
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique
A moderate diffuse dilation was seen at the biliary tree with
the CBD measuring 13 mm.
The cholangiogram did not definitively show a filling defect in
the distal CBD. However given the clinical picture suggestive
of gallstone pancreatitis and the finding of bulging ampulla
concerning for an impacted stone, a decision was made to perform
a sphincterotomy.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A single stone was extracted successfully using a balloon.
Two more balloon sweeps were performed that did not reveal
additional stones or sludge.
Otherwise normal ercp to second part of the duodenum
[**2102-3-26**] 06:10AM BLOOD ALT-132* AST-25 LD(LDH)-223 AlkPhos-159*
TotBili-0.7
Brief Hospital Course:
ICU Course:
66F with PMHx of hypertension, s/p CCY [**2089**], who was transferred
to [**Hospital1 18**] from LGH for acute gallstone pancreatitis s/p ERCP
w/sphincterotomy [**3-22**], hospital course complicated by new onset
atrial fibrillation with rapid ventricular response.
# Afib w/RVR: After the ERCP, the patient developed new-onset
afib w/RVR. Etiology unclear, possibly related to
hypersympathetic tone in the context of acute pancreatitis. TSH
was normal. Cardiac enzymes were negative. Did not anticoagulate
her given CHADS2 score of 1 and bleeding risk from
sphincterotomy [**3-22**] during ERCP. A TTE was performed which
showed normal global and regional biventricular systolic
function, However there was mild left atrial dilatation which
may have been a cause or effect of the atrial fibrillation. The
patient spontanously converted back to sinus rhythm. Given her
CHADS 2 score, use of both aspirin and plavix can be considered.
She was started on aspirin alone, and advised to discuss with
her PCP any additional use of plavix.
# Hypoxemia: Most likely secondary to flash pulmonary edema in
the context of fluid resuscitation and new atrial fibrillation.
Resolved.
# Pancreatitis: Patient is s/p ERCP with sphincterotomy and
stone extraction. LFTs are trending down and she reports
improvement in her abdominal pain. Will continue symptom
management. LFTs improved over course of hospitalization.
# Leukocytosis: Patient presented with normal WBC 6.4 on
admission, which rose to 16.8. Likely due to inflammation from
acute pancreatitis. S/p ERCP w/sphincterotomy; no evidence of
cholangitis on ERCP, but given low-grade fevers (99.5) and
increasing leukocytosis, started empiric cipro. No evidence of
pneumonia on CXR. She will complete one week of ciprofloxacin
at home.
# Hypertension: She was discharged on amlodipine and
metoprolol. She will f/u with her PCP for continued blood
pressure management.
# ? NASH/hepatic fibrosis on ultrasound. PCP should discuss
dietary measures, consider liver biopsy to further assess.
Medications on Admission:
Home medications:
Per [**Company 25282**] -
she does not know her medications
Metoprolol tartare 25 mg po bid
lisinopril 10 mg po bid
HCTZ 12.5 mg po daily (last refilled in [**Month (only) 958**])
amlodipine 5 mg po daily (last refilled in [**Month (only) 958**])
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*5 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*10 Tablet(s)* Refills:*0*
5. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
atrial fibrillation
pumonary edema
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
pancreatitis caused by gallstones. An ERCP was performed to
remove the stone. Your course was complicated by Atrial
Fibrillation (irregular heart rhythm) with rapid heart rate and
fluid in the lung requiring ICU stay. Your heart rate was
controlled and you were moved back to the medical floor. You
were able to start eating on [**2102-3-26**]. You will need to follow up
with your PCP to discuss treatment for Atrial Fibrillation with
at least daily aspirin, but this may also include an additonal
medication, Clopidogrel. You need to complete one week of
antibiotic treatment with ciprofloxacin and this will end on
[**3-30**].
In regards to your blood pressure, please take metoprolol 25 mg
by mouth twice a day, and restart the amlodipine at 5 mg daily.
Hold the hydrochlorothiazide and lisinopril until you see Dr
[**Last Name (STitle) 63252**] on [**Last Name (STitle) 2974**]. Please start taking a baby aspirin every
day starting on [**3-30**]. You may take dulcolax (bisacodyl)
to help you move your bowels.
Followup Instructions:
PCP [**Name Initial (PRE) **]: [**Last Name (LF) 2974**], [**3-31**] at 4:15pm
With: [**Name6 (MD) **] [**Name8 (MD) **],MD
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 46646**]
Phone: [**Telephone/Fax (1) 34574**]
|
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30,775
| 103,093
|
43226
|
Discharge summary
|
report
|
Admission Date: [**2144-10-3**] Discharge Date: [**2144-10-6**]
Date of Birth: [**2064-12-3**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine / Ranitidine
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 24214**] is a 79 F with h/o seizures now transferred from
neurosurg service for workup of syncope. Pt was in USOH on
[**2144-10-3**] when had apparent syncope while grocery shopping. She
remembers purchasing groceries and walking outside and seeing
her car. Next thing she remembers is waking up on ground near
her car surrounded by people. No aura/prodrome. No postictal
confusion, no incontinence or tongue biting. There were many
people around; no reported tonic-clonic activity. No HA, fever,
palpitations, N/A, weakness, numbness. Notes that it was a hot
day and she had not had much to eat or drink.
.
Pt has history of 2 or 3 prior seizure events, last more than 20
years ago. Has been on Dilantin for many years. During prior
seizures she was observed to have GTC activity, aura, post ictal
confusion, +/- urinary incontinence. She does not feel that
this particular episode was similar to her prior seizures. She
does have a history of atrial tachycardia to 160's during prior
admission, asymptomatic. She also notes one month history of
intermittent regularly irregular heartrate (skipped beats, see
[**9-11**] PN from Dr. [**Last Name (STitle) 1007**]. Notes this when feeling her pulse but
is otherwise asymptomatic. She also had a mechanical fall down
stairs at her house about 1 week PTA. States she fell on her
hip; did not hit her head but did hit the back of her neck. No
LOC.
.
In [**Name (NI) **] pt found to have subdural hematoma and admitted to
neurosurgery. By CT hematoma has shown stability. Transferred
to medicine for workup of her syncope.
Past Medical History:
Seizure disorder, last Sz about 20 y ago, on dilantin.
Chronic HA
OA
Osteopenia
Endometrial polyp
h/o atrial tachycardia during admit [**3-/2137**]
Tricuspid regurg (mod-severe on echo)
Social History:
Retired social worker. Denies EtOH, illicits. Past h/o
smoking, quit 20 years ago.
Family History:
Cousin with Sz disorder, mother with MI, father with COPD
Physical Exam:
VS: T 96, P 71, R 18, BP 118/64, O2 sat 98%
Orthostatics: Lying 110/66; sitting 120/72; standing 132/74
General: Thin, elderly female, NAD
HEENT: Ecchymosis/edema under L orbit. Healing skin tear at
hairline of L forehead, no active bleeding. PERRL, EOMI. OP
clear. No oral trauma. MMM.
Neck: full ROM, no carotid bruit
Chest: CTA bilat
Heart: RRR with occ early then skipped beat (~one out of [**1-9**]
beats). S1 S2, 2/6 systolic murmur at LLSB.
Abdomen: +BS, slightly distended, soft, NT. Tympanic
throughout, no shifting dullness.
Extrem: Thin, no edema. Normal muscle tone, bulk.
Neuro Exam:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-28**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-30**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
No pronator drift
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2144-10-3**]
WBC-5.3 HGB-12.5 HCT-35.8* MCV-96 RDW-14.0 PLT-271
NEUTS-69.7 LYMPHS-24.3 MONOS-4.2 EOS-1.2 BASOS-0.5
PT-12.7 PTT-27.3 INR(PT)-1.1
GLUCOSE-103 UREA N-12 CREAT-0.5 SODIUM-134 POTASSIUM-3.8
CHLORIDE-97 TOTAL
CO2-28 ANION GAP-13
CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.4
PHENYTOIN-13.2
ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
CT head: Right subdural hematoma (3.1 x 1.1), appearing
partially organizing, with local mass effect, as described
above. Mixed density in the adjacent subdural space may
represent hyperacute-on-acute bleeding or acute-on-chronic
bleeding. Superficial soft tissue swelling along the left
frontal region. There is local mass effect, without shift of
normally midline structures.
.
CT head (repeat [**10-4**]) No increase in size in the right subdural
hematoma.It may be slightly decreased in size.
.
CT head (repeat [**10-5**]) Stable right-sided subdural hematoma
.
CXR: No displaced rib fracture or acute cardiopulmonary process.
.
ECG: Sinus rhythm at 71. Frequent ventricular premature beats.
Left axis deviation with left anterior fascicular block.
.
CT spine: Prevertebral soft tissue structures are normal.
Advanced degenerative changes are present at C5 through C7 with
anterior osteophytes, subchondral sclerosis, and joint space
narrowing. Multilevel degenerative changes are present in the
facet joints. No acute fracture or dislocation is identified.
.
Echo ([**2142-4-6**]): The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated. The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is no pericardial effusion.
.
Review of telemetry: No Vtach. Frequent PVCs, no couplets, at
times trigeminy or every fourth beat is PVC.
Brief Hospital Course:
A&P: Ms. [**Known lastname 24214**] is a 79 F with h/o seizure disorder on
Dilantin, multiple PVCs on telemetry, h/o atrial tachycardia;
initial admit to neurosurgery with subdural hematoma (now
stable); transfer to medicine for syncope workup.
.
# Syncope: Pt's fall and LOC seemed most consistent with syncope
(vs. seizure). Although she had h/o seizure disorder, this
episode was not c/w priors. No prodrome, no postictal
confusion, no incontinence/tongue biting. Stated that she did
not remember good chunk of time prior to her LOC. Other DDx
included vasovagal, cardiac arrhythmia, orthostasis, mechanical
fall with concussion. Her orthostatics were normal. Carotid
dopplers were normal. She had a normal EEG. Echo was unchanged
from previous (normal EF, no aortic stenosis). She had frequent
PVCs here (frequently in trigeminy) but no NSVT or couplets. EP
was consulted and saw no evidence of syncope due to arrhythmia.
Could be vasovagal (hot weather, etc). No known
toxins/electrolyte abnormalities. Neurology was also consulted
and autonomic tilt table testing was done (report pending). She
also had some unsteadiness on her feet (unclear how much of this
was due to the SDH) with occasional falls at home. It was also
quite likely that she had a mechanical fall with head trauma
severe enough to cause mild retrograde amnesia. She was
instructed not to drive until seeing her PCP [**Name Initial (PRE) **]/or neurologist.
.
# Subdural hematoma: Initially admitted to neurosurgery. She
had serial CT scans to evaluate progression and the hemorrhage
continued to show stability/improvement. There was no
neurologic deficits. She will followup with neurosurgery as an
outpatient.
.
# Seizure disorder. She had had no seizure x 20 years but has
continued on dilantin mainly because she has felt uncomfortable
off antiepileptics. Dilantin level was within range. She had a
neurology consult and EEG as above.
.
# Osteopenia: contined Fosamax. Also encouraged her to take
calcium and vitamin D.
.
# Anemia: Normocytic, near baseline and stable.
.
# Hyperlipidemia: continued atorvastatin
Medications on Admission:
Dilantin 300 mg QAM, 400 mg QPM
Fosamax 35 mg Qweek
Lipitor 10 mg QHS
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: [**2-29**] Capsules PO
BID (2 times a day): Please take Dilantin as per prior dosing
(200 mg twice daily alternating with 200 mg in AM and 300 mg in
PM).
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
Syncope
Seizure disorder
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for an episode of falling with a related head
injury. There was a small amount of bleeding inside your head
(subdural hematoma) that has not changed while we have been
monitoring you. You will followup with the neurosurgeons in the
future. We also tried to figure out why you had this fall. We
looked at your heart rhythms and brain rhythms to look for
abnormalities. So far we have not been able to uncover a
definite reason for why you had this fall.
.
Please DO NOT DRIVE until you followup with your primary care
physician and your neurologist.
.
Please return to the hospital if you have further episodes of
fainting, seizure, dizziness, palpitations, difficulty with
memory or confusion, or any new symptoms that you are concerned
about.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 1007**] ([**Telephone/Fax (1) 10492**]) to schedule a followup
appointment in 1 week.
.
We would like you to followup with Dr. [**Last Name (STitle) 2442**] again regarding
your seizures and Dilantin. Please call ([**Telephone/Fax (1) 5563**] to
schedule an appointment with him in [**2-29**] weeks.
.
The neurosurgery team (Dr. [**Last Name (STitle) **] will be in contact with you
to schedule a followup appointment. Please call ([**Telephone/Fax (1) 88**]
if you do not hear from them within one week.
.
You also have the following upcoming appointments at [**Hospital1 18**]:
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2144-12-3**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 24672**], MD Phone:[**Telephone/Fax (1) 24673**]
Date/Time:[**2145-4-1**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
"272.0",
"780.2",
"345.90",
"852.26",
"E885.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8958, 8964
|
6358, 8468
|
313, 320
|
9051, 9060
|
4074, 4455
|
9997, 11050
|
2283, 2342
|
8589, 8935
|
8985, 9030
|
8494, 8566
|
9084, 9974
|
2357, 2961
|
266, 275
|
348, 1956
|
3253, 4055
|
4464, 6335
|
2976, 3237
|
1978, 2165
|
2181, 2267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,586
| 197,044
|
39742
|
Discharge summary
|
report
|
Admission Date: [**2113-8-17**] Discharge Date: [**2113-9-5**]
Date of Birth: [**2031-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Called by Emergency Department to evaluate
transfer from OSH for right basal ganglia bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 year old right handed man with unknown past medical
history (although son mentions he may have HTN and diet
controlled diabetes) who has not seen a physician in years who
was "found down" this morning in his home and now transferred
for
right basal ganglia hemorrhage.
As per son, his father was independent and he had not spoken to
him in several days. Apparently he was last seen by a neighbor
2-3 days ago. Today a neighbor [**Name (NI) 653**] the building manager
and
then found him on the floor with left sided weakness. He was
brought to [**Hospital6 4287**] where they documented that he was
conversant and that he said he fell several days ago and had a
headache. He was tachycardic to 131, BP 144/79-160/89, was
dehydrated, and had a stage I decub over his scapula. Given 2L
NS, labs sent, and CT head showed the bleed. CT cervical spine
without fracture and sent with a C collar to [**Hospital1 18**] ED for
further
evaluation.
In the ED, BP 140/80. Neurosurgery evaluated the patient and
imaging repeated without change in the size of the bleed.
Additional labs sent and he was admitted to the ICU for further
management.
Past Medical History:
- son says probably has HTN (not on medications)
- son says may have diet controlled diabetes
Social History:
Lives alone and does his own ADLS. Does not drive and
walks with cane occasionally. Remote smoking hx (quit > 30 years
ago) and occasional beer. Retired mechanic. DNR/DNI per son
[**Name (NI) 79942**] ([**Name2 (NI) **]) [**Known lastname 17204**] [**Name (NI) **]
[**Telephone/Fax (1) 87544**].
Family History:
Unremarkable
Physical Exam:
HEENT: NC/AT, dry MMM,
Neck: C collar in place
Pulmonary: Lungs CTA
Cardiac: RRR, nl. S1S2,
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: bruising on toes
Neurologic:
-Mental Status: awake, follows some commands to open eyes,
squeeze hands, speech is dysarthric, and he mumbles a sentence
about getting a cold drink and then falling
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm reactive.
III, IV, VI: unable to test
V: Facial sensation intact to light touch.
VII: left facial droop
VIII: Hearing intact
-Motor: Normal bulk, tone throughout.
moving right upper and lower purposefully and does withdraw left
upper and lower extremtiy to pain
right upper and lower extremity hypertonic
-Sensory: withdraws
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
left toe up.
-Coordination and gait: untested
Pertinent Results:
Admission Labs
[**2113-8-17**] 05:35PM WBC-12.9* RBC-4.47* HGB-13.4* HCT-39.7*
MCV-89 MCH-30.1 MCHC-33.8 RDW-13.8
[**2113-8-17**] 05:35PM NEUTS-86.6* LYMPHS-9.0* MONOS-4.0 EOS-0.1
BASOS-0.3
[**2113-8-17**] 05:35PM GLUCOSE-248* UREA N-43* CREAT-0.7 SODIUM-135
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
.
Pertinent Labs
[**2113-8-24**] 06:45AM BLOOD WBC-18.3*# RBC-4.12* Hgb-12.4* Hct-36.2*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.9 Plt Ct-196
[**2113-8-31**] 11:51AM BLOOD WBC-7.9 RBC-3.49* Hgb-10.6* Hct-31.2*
MCV-89 MCH-30.4 MCHC-34.1 RDW-13.9 Plt Ct-224
[**2113-9-2**] 08:25AM BLOOD WBC-8.7 RBC-3.58* Hgb-10.8* Hct-30.8*
MCV-86 MCH-30.1 MCHC-35.0 RDW-13.6 Plt Ct-266
[**2113-9-5**] 08:00AM BLOOD WBC-9.9 RBC-3.83* Hgb-11.5* Hct-33.1*
MCV-87 MCH-30.1 MCHC-34.9 RDW-14.4 Plt Ct-318
[**2113-9-5**] 08:00AM BLOOD PT-15.2* INR(PT)-1.3*
[**2113-9-5**] 08:00AM BLOOD Glucose-162* UreaN-13 Creat-0.4* Na-134
K-4.2 Cl-100 HCO3-30 AnGap-8
[**2113-8-31**] 07:10PM BLOOD ALT-25 AST-21 LD(LDH)-250 AlkPhos-118
TotBili-0.5
[**2113-8-24**] 08:18AM BLOOD CK-MB-3 cTropnT-<0.01
[**2113-8-24**] 03:53PM BLOOD CK-MB-3 cTropnT-<0.01
[**2113-8-24**] 11:54PM BLOOD CK-MB-3 cTropnT-<0.01
[**2113-9-4**] 07:00AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.8
[**2113-8-18**] 03:04AM BLOOD %HbA1c-11.2* eAG-275*
.
Pertinent Reports
NCHCT Study Date of [**2113-8-17**] 8:05 PM
Unchanged right basal ganglia parenchymal hemorrhage with trace
intraventricular and mild subarachnoid extension and surrounding
edema,
without new bleeding. Stable mass effect on right lateral
ventricle, without herniation. Appearance suggests hypertensive
etiology. CTA head: Patent vasculature without stenosis,
occlusion, aneurysm or anomaly.
.
RUQ US ([**2113-9-1**]): Partially sludge-filled gallbladder. No
specific signs of cholecystitis identified.
.
CT Abdomen ([**2113-9-1**]): left effusion with atlectesis, infection
at lung base not excluded. free intra-abdominal air compatible
with recent ([**8-30**] PEG placement). PEG in stomach. large volume
stool in colon. no bowel obstruction. patent mesenteric
vasculature, but moderate atherosclerotic dz.
.
CT Head ([**2113-9-1**]): Stable appearance to right basal ganglia
hemorrhage without new hemorrhage or midline shift.
.
Bilateral Hip films ([**2113-8-29**]): Right trochanteric calcific
bursitis. No fracture or bone destruction.
.
CXR ([**2113-8-31**]): New opacities in the left lung are worrisome for
aspiration. Cardiomediastinal contours are unchanged. Aeration
of the right lung has improved. There is no evident pneumothorax
or large pleural effusion.
.
CT abd (prelim read): ? cholecystitis, 2 lung nodules, will need
follow up in 3 months
Brief Hospital Course:
# R basal ganglia hemorrhage: patient was admitted with R basal
ganglia hemorrhage with temporal lobe involvement. He was found
down in his apartment after an unknown period of time. In the
ICU his exam was notable for being responsive to voice, but
having erratic and disturbed consciousness. He was moving his
right upper and lower extremities purposefully and withdrawing
on the left. He was disoriented and pulled out 3 Dobhoff feeding
tubes. He did not originally pass his speech and swallow test.
Repeat testing was scheduled. Pressures were well controlled in
the unit and patient was transferred to the floor. On the
neuro-floor the patient had a repeat speech and swallow
evaluation and had failed x2. PEG tube was placed on transfer to
the medicine floor. His neurologic examination remained
unchanged except for mild improvement in his speech (slight less
dysarthria).
.
# Tachycardia, BP lability: a stat EKG was ordered and gathered
after 5mg IV metoprolol push x1. Rhythm was sinus tachycardia no
obvious ST elevation/ depression noted. 5mg IV metoprolol
resulted in HR decreasing to 100's. SBP still >160. Pt within
5-9 min had decreasing alertness a code blue was called although
he had a stable Blood pressure. 5mg IVP metoprolol was given
again. Pts pressure unresponsive to these IV pushes and pt was
transferred to the MICU team for aggressive blood pressure
control with IV drips and a repeat CT head was ordered to
evaluate expansion of the hemorrhage given acute hypertensive
emergency, with no change noted. He was transitioned to PO
lisinopril with adequate BP control thereafter, subsequently
became hypotensive after PEG tube placement and was treated for
septis as below
.
#Fever/hypotension: initially concerning for urosepsis with cx
positive for ecoli, also concern for infection at PEG site
placement. Surveillance blood cultures from [**2113-8-25**], [**2113-8-26**]
and [**2113-8-31**] were negative. Urine cultures form [**2113-8-31**] were
negative. The patient eventually grew E.Coli from both blood
and urine cultures that was pansensitive and he was transitioned
to ciprofloxacin for a 14 day course, and the IV vancomycin and
cefepime were discontinued. He will require cipro until
([**2113-9-7**]). Two blood cxs were pending on discharge and will
require follow up.
.
# Right sided eye pain: ophthomology consulted who recommended
erythomycin ointment. He was treated with a 10 day course of
abx eye ointment.
.
# Diarrhea/abd pain: concern for c. diff vs PEG site infection,
vs cholangitis (final CT read pending on dc, however no signs of
obstruction or acute process). He was started on PO
vanco/flagyl, c. diff was negative x 1 and diarrhea resloved.
Pt then became constipated x3 days and required bowel regimen.
Second c. diff was sent, pending. If negative, would dc PO
vanc, continue flagyl for total 7 day course (last day [**9-7**]). If
positive, would continue PO vanc and flagyl for total 14 days
(last day [**9-14**]).
.
# Lung nodules: on CT. Will need repeat CT in [**1-8**] months to
ensure resolution.
.
# Persistent HAs: A head CT was performed and showed stable
right basal ganglia hemorrhage with resolution of
intraventricular and subarachnoid hemorrhages, no new
hemorrhage, and no evidence of herniation. Q8h neuro checks
revealed no new deficits. The patient's stable headaches were
treated with morphine, oxycodone and tylenol.
.
#) COPD: - Per his family's report he has a history of emphysema
and was started on nebs with good results. ipratropium nebs q6
PRN. He required 2L by NC to maintain sats in 90s at times,
however was without complaints of SOB.
.
#) Diabetes: Well controlled with glargine and sliding scale
insulin.
.
#) Elevated INR: Likely nutrional deficiency. Given Vitamin K
po during this hospital stay to keep INR < 1.5.
.
#) Anemia: stable, no signs of active bleed. Iron studies
pending on dc. Will require f/u in the outpt setting.
.
#) Code status: DNR/DNI confirmed with HCP, son.
Medications on Admission:
On admission: unknown.
On transfer from neurosurgery:
HydrALAzine 10 mg IV Q6H:PRN SBP>155
Morphine Sulfate 1 mg IV Q12HRS PRN Mod-Sev Pain
Heparin 5000 UNIT SC TID
Docusate Sodium 100 mg PO TID
Senna 2 TAB PO/NG HS
Multivitamins 1 TAB PO/NG DAILY
Insulin SC
Dextrose 50% 12.5 gm IV PRN hypoglycemia
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia
Ondansetron 4 mg IV Q8H:PRN nausea
Famotidine 20 mg IV Q12H
Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID
Lisinopril 20 mg PO/NG DAILY
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for resp distress.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO TID (3
times a day).
3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. insulin
Per sliding scale
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
10. Vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 9 days: Ok to stop if second c diff negative.
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Hold for SBP<100.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily): ok to hold if >2 BMs/day.
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
15. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
16. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 9 days: Continue
until [**9-14**], can discontinue on [**9-7**] if second c. diff comes back
negative.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnosis
1. Right basal ganglia hemmorhage
2. E. Coli urosepsis
3. Eye pain
4. Abd pain/diarrhea concerning for c diff, negative cxs.
.
Secondary Diagnosis
1. Hypertension
2. Diabetes Mellitus
3. Pulmonary nodules
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted because you had a stroke. Your hospital stay
was complicated by infection in your blood and urine which
required an antibiotic called CIPROFLOXACIN for 14 days. You
were not able to eat so a tube was placed in your stomach to
feed you. It was thought you had an infection in your gut with
bacteria called CLOSTRIDIUM DIFFICILE so you were started on
antibiotics called METRONIDAZOLE AND VANCOMCYIN. You were
discharged to a rehabilatation facility to help recover your
strength.
.
As your medications on admission were unknown, all medications
started in the hospital are new. Please take them as
prescribed.
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2113-10-3**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 1694**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please make an appointment with your primary care physician
[**Name Initial (PRE) 176**] 1-2 weeks of leaving rehab facility.
|
[
"784.51",
"599.0",
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"286.7",
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"342.92",
"719.45",
"787.91",
"437.9",
"276.51",
"511.9",
"401.9",
"431",
"787.20",
"707.21",
"250.00",
"996.64",
"E879.6",
"038.42",
"348.5",
"707.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.6",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
11831, 11903
|
5702, 9692
|
405, 411
|
12170, 12170
|
3011, 5679
|
12964, 13422
|
2031, 2045
|
10224, 11808
|
11924, 12149
|
9718, 9718
|
12309, 12941
|
2461, 2992
|
2060, 2278
|
274, 367
|
439, 1581
|
9732, 10201
|
12185, 12285
|
1603, 1699
|
1715, 2015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,738
| 168,894
|
50001
|
Discharge summary
|
report
|
Admission Date: [**2140-4-19**] Discharge Date: [**2140-4-26**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of a brain abscess complicated by residual
memory impairment and hyperlipidemia who was admitted on
[**4-19**] with a left femoral fracture in the setting of
falling when out of bed. The etiology of the fall was
unclear. The patient had declined any chest pain, shortness
of breath, or syncope.
The patient was admitted to Orthopaedics and taken to the
operating room on [**4-19**] for a left bipolar hip
arthroplasty. The immediate postoperative course was
complicated by an episode of oxygen desaturation; she was
100% on 30% face mask and 88% on room air. Later that
evening, on [**4-19**], the patient developed diffuse left-sided
chest pain, [**8-28**] to [**5-28**] after two sublingual nitroglycerin
tablets. She was sent for a computed tomography angiogram to
rule out pulmonary embolism, and cardiac enzymes were cycled
to rule out myocardial infarction, and was empirically
started on a heparin drip for treatment of pulmonary embolism
or acute coronary syndrome.
On the morning of [**4-20**], following the computed tomography
angiogram and heparin initiation, the patient was noted to be
hypotensive with complaints of chest pain without any change
in mental status. She was bolused a total of 3 liters of
normal saline without sustainable improvement in her chest
pain.
Of note, the patient had new T wave inversions in V2 through
V4 and new 0.5-mm ST depressions in lead II. She was also
complaining of severe left hip pain that was greater than her
chest pain during the entire above episode.
The patient was transferred to the Medical Intensive Care
Unit for management of blood loss anemia secondary to a
hemorrhage from surgical wound in the setting of a
supratherapeutic anticoagulation after surgery for
prophylaxis during pulmonary embolus rule out.
The Medical Intensive Care Unit course was complicated by
continued bleeding from the surgical wound requiring a
transfusion of a total of 10 units of packed red blood cells,
with the last transfusion on [**4-22**]. She was continued on
Lovenox until [**4-22**], as Orthopaedics was concerned of an
increased risk of pulmonary embolism greater than blood loss.
The Lovenox was eventually discontinued. She was ruled out
for a myocardial infarction for a total of three times. The
patient's chest pain was thought not secondary to cardiac
origin with the plan for a stress or catheterization at a
later time when the patient was stable from an orthopaedic
standpoint. She is status post treatment for a urinary tract
infection with Levaquin. She is now transferred to the
floor.
PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. Spinal stenosis.
3. Osteoarthritis.
4. Brain abscess with left facial weakness.
5. Obstructive sleep apnea; not on continuous positive
airway pressure secondary to intolerance.
6. A right hip fracture; status post open reduction/internal
fixation with osteonecrosis.
7. Left corneal abrasion/scar.
ALLERGIES: PENICILLIN, ERYTHROMYCIN, BETADINE, BACITRACIN
(the reactions to these were unknown).
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Aricept 5 mg p.o. q.d.
2. Colace.
3. Fosamax 10 mg p.o. q.d.
4. Imdur 30 mg p.o. q.d.
5. Neurontin 100 mg p.o. t.i.d.
6. Oxybutynin 5 mg p.o. b.i.d.
7. Prednisone 5 mg p.o. q.d.
8. Hyoscyamine 250 mg p.o. t.i.d.
9. Timolol 0.25% right eye q.h.s.
MEDICATIONS ON TRANSFER: (Her medications on transfer from
the Medical Intensive Care Unit included)
1. Donepezil 5 mg p.o. q.6h.
2. Colace 100 mg p.o. b.i.d.
3. Alendronate 10 mg p.o. q.d.
4. Gabapentin 100 mg p.o. t.i.d.
5. Oxybutynin 5 mg p.o. b.i.d.
6. Timolol 0.25% one drop right eye q.d.
7. Morphine sulfate 2 mg to 4 mg intravenously q.4h. as
needed.
8. Sublingual nitroglycerin.
9. Prednisone 5 mg p.o. q.d.
10. Regular insulin sliding-scale.
11. Pantoprazole 40 mg p.o. q.24h.
12. Tylenol.
13. Trazodone 50 mg p.o. q.h.s. as needed.
SOCIAL HISTORY: A 50-pack-year tobacco history; half to one
pack per day.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on transfer from the Medical Intensive Care Unit revealed
temperature was 97.9, heart rate was 79, blood pressure was
122/47, respiratory rate was 12, and oxygen saturation was
100% 3 liters. Ins-and-outs were negative 1.83 liters out.
In general, a pleasant elderly female lying in bed, in no
acute distress. Head, eyes, ears, nose, and throat
examination revealed left eye surgical. Right eye pupil was
reactive. No jugular venous distention. No carotid bruits.
Mucous membranes were dry. A left facial droop. Left eye
droop; closed. Heart examination revealed a regular rate and
rhythm. Normal first heart sounds and second heart sounds.
No murmurs, rubs, or gallops. Lung examination revealed
right lower lobe with crackles. The rest of the lungs were
clear to auscultation bilaterally. The abdomen was soft,
nontender, and nondistended. Bowel sounds were positive.
Extremity examination revealed pneumo boots, left ankle with
an ACE bandage, left hip dressing was clean, dry, and intact
with minimal bleeding, 1 to 2+ edema. Neurologic examination
revealed alert and oriented times three.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her white blood
cell count was 11.8, her hematocrit was 30.8, and her
platelets were 154. Her prothrombin time was 12.7, her
partial thromboplastin time was 25.4, and her INR was 1.1.
Sodium was 140, potassium was 4.3, chloride was 110,
bicarbonate was 22, blood urea nitrogen was 35, creatinine
was 1, and blood glucose was 93. Calcium was 8, phosphorous
was 2.4, and magnesium was 2.
HOSPITAL COURSE BY ISSUE/SYSTEM: Essentially, this is an
81-year-old female with a history of a brain abscess
complicated by residual memory impairment who was admitted on
[**4-19**] with a left hip fracture, status post a left hip
arthroplasty. Her postoperative course was complicated by a
hemorrhage from the surgical wound requiring 10 units of
packed red blood cells and multiple episodes of chest pain
(ruling out for a myocardial infarction during each of these
episodes).
1. ORTHOPAEDIC ISSUES: The patient was status post left hip
arthroplasty. The issue of anticoagulation status post
surgery was a difficult one given the increased risk of
pulmonary embolus, status post the orthopaedic surgery.
However, given that the patient had significant bleeding, it
was decided by the Orthopaedic team that she would be placed
on aspirin 81 mg p.o. q.d. as her form of anticoagulation.
The patient should be following up with the orthopaedic
surgeon (Dr. [**Last Name (STitle) 9694**] in one week from her discharge, and she
was to call telephone number [**Telephone/Fax (1) 4301**] to make an
appointment.
The patient had also complained of ankle pain on the left
side, and it was unclear whether when she had originally
fallen and sustained a hip fracture if she had also developed
an ankle fracture. The ankle film showed diffuse osteopenia
with soft tissue swelling about the ankle, but no fracture
had been identified.
She was seen by Physical Therapy, and it was deemed that she
would benefit from rehabilitation.
The patient also has a history of osteoarthritis and was on
prednisone 5 mg p.o. per day. The patient's wound was slow
to heal; likely thought secondary to her prednisone use. She
also has a history of some serosanguineous drainage from the
wound, so it was thought that she would benefit from a 1-week
course of Keflex 500 mg p.o. q.i.d. that she was started on
on the day of discharge (on [**2140-4-26**]).
2. CARDIOVASCULAR SYSTEM: The patient has no known coronary
artery disease with a stress MIBI in [**2136**] showing no
perfusion defects; however, she had multiple episodes of
chest pain, and one episode with electrocardiogram changes.
Otherwise, her enzymes were flat. Thus, it was unclear if
this was cardiac in etiology.
The plan was for further risk stratification with a stress
MIBI or catheterization when she was stable from an
orthopaedic standpoint.
We continued her on metoprolol which was initiated while she
was in the hospital at 12.5 mg p.o. b.i.d., and she was
started on aspirin again for anticoagulation postoperatively
and also for cardiovascular benefit.
3. NEUROLOGIC ISSUES: The patient has a history of a brain
abscess complicated by memory impairment. She was continued
on Aricept 5 mg p.o. q.d. and gabapentin 100 mg p.o. t.i.d.
for a history of neuropathy.
4. GENITOURINARY ISSUES: The patient has a history of
urinary incontinence, which she exhibited while she in the
hospital. She was continued on oxybutynin 5 mg p.o. b.i.d.
5. OPHTHALMOLOGIC ISSUES: She was continued on Timolol.
6. PULMONARY ISSUES: Pulmonary wise, the patient's
respiratory status was stable. We monitored her respiratory
rate and oxygen saturation which were stable throughout her
hospitalization. There was a low threshold for obtaining a
computed tomography angiogram. She had pleuritic chest pain
with decreased oxygen saturations. However, this was not
exhibited during her hospitalization. Of course, the risk
was still for a pulmonary embolism given her proximity to
recent orthopaedic surgery.
7. INFECTIOUS DISEASE ISSUES: The patient had a low-grade
temperature once during her hospitalization with a white
blood cell count of 15. Her white blood cell count was
unexplainable as there was no focal signs or symptoms. She
had a Foley catheter until urinalysis was checked (which was
negative for any signs of infection). Given that she had
previously had minor serosanguineous drainage and was on
prednisone, we thought it was reasonable to start her on a
7-day course of Keflex for treatment of postoperative
surgical wound, and she was to continue on this for one week.
8. HEMATOLOGIC ISSUES: The patient's hematocrit remained
stable after the Lovenox was discontinued, and her creatinine
remained between 30 and 35 with no more evidence of continued
bleeding, and no more increase in left hip pain. She
continued to be monitored during her hospitalization.
DISCHARGE STATUS: The patient was discharged to an extended
care facility; [**Location (un) **].
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to seek medical attention if she develops
worsening left hip pain, acute shortness of breath, or any
other symptoms of concern.
2. The patient was to follow up with Orthopaedics as
previously mentioned with Dr. [**Last Name (STitle) 9694**] in one week. The
patient was to call telephone number [**Telephone/Fax (1) 4301**] to make an
appointment.
FINAL DISCHARGE DIAGNOSES:
1. Left hip fracture.
2. Status post total hip arthroplasty.
3. Blood loss anemia.
4. Atypical chest pain.
MAJOR SURGICAL/INVASIVE PROCEDURES: Her major
surgical/invasive procedures were left hip arthroplasty.
CONDITION AT DISCHARGE: The patient was ambulating with
physical therapy assistance, tolerating oral intake,
urinating, and was having bowel movements.
MEDICATIONS ON DISCHARGE: (Her discharge medications
included)
1. Aricept 5 mg p.o. q.d.
2. Alendronate 10 mg p.o. q.d.
3. Gabapentin 100 mg p.o. t.i.d.
4. Oxybutynin 5 mg p.o. b.i.d.
5. Timolol 0.25% one drop right eye q.d.
6. Metoprolol 12.5 mg p.o. b.i.d.
7. Aspirin 81 mg p.o. q.d.
8. Prednisone 5 mg p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Keflex 500 mg p.o. q.6h. (for seven days; the start date
was [**2140-4-26**]).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 9633**]
MEDQUIST36
D: [**2140-4-26**] 10:09
T: [**2140-4-26**] 10:12
JOB#: [**Job Number 104399**]
|
[
"599.0",
"625.6",
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"998.11",
"780.57",
"786.59",
"285.1",
"820.8",
"724.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
11113, 11800
|
3199, 3489
|
10317, 10688
|
5771, 10284
|
10957, 11086
|
10715, 10942
|
111, 2723
|
3515, 4056
|
2745, 3172
|
4073, 5736
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,137
| 129,037
|
21834
|
Discharge summary
|
report
|
Admission Date: [**2113-3-17**] Discharge Date: [**2113-3-24**]
Date of Birth: [**2031-11-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Lateral extracavitary approach for a T11 and T12
vertebrectomy and resection of metastasis.
2. Insertion of pedicle screws from T9 through L2.
3. Posterolateral arthrodesis, T9 to L2.
4. Anterior arthrodesis, T10-T11, T11-T12, T12-L1 and L1-L2.
5. Insertion of an anterior expandable cage.
6. Harvest of bone marrow aspirate from the right posterior-
superior iliac crest for use in fusion.
7. Local autograft for arthrodesis.
History of Present Illness:
This 82-year-old gentleman presents with a history of a melanoma
metastasis to
the thoracolumbar junction. He underwent a posterior resection
at T11-T12, which was known to be subtotal at that time. In the
interval from [**Month (only) **] to [**Month (only) 1096**], serial scans have shown
progressive enlargement of that metastatic lesion. He has
intractable back pain and is currently on OxyContin. Otherwise,
he is asymptomatic with no difficulty with either bowel,
bladder,
or ambulatory function. His postoperative course was complicated
by wound infection.
Past Medical History:
His past medical history is significant for colon cancer for
which he underwent resection as well as the melanoma as
discussed. He also has an arrhythmia.
Social History:
His review of systems is noncontributory. He does not smoke.
Family History:
noncontributory
Physical Exam:
On examination, his motor strength was normal in the lower
extremities. His sensory examination was intact. His reflexes
were normal and symmetric. There was no point tenderness in the
thoracolumbar junction. His old incision was well-healed and was
somewhat retracted. There was no clonus.
Pertinent Results:
An MRI of the thoracic spine demonstrates a metastatic lesion
which is significantly involving the T12 vertebral body. There
is some extension to the dorsal aspect of the T11 vertebral
body.
There is epidural extension to the T8-T9 disc space.
Brief Hospital Course:
Pt was admitted on [**3-17**] and underwent embolization of his
thoracic masses in IR. He tolerated this procedure well and was
transferred to PACU and then floor. He did have hematoma at
right groin site. On [**3-20**] he went to the OR for Lateral
extracavitary approach for a T11 and T12vertebrectomy and
resection of metastasis, Insertion of pedicle screws from T9
through L2, Posterolateral arthrodesis, T9 to L2, Anterior
arthrodesis, T10-T11, T11-T12, T12-L1 and L1-L2, Insertion of an
anterior expandable cage, Harvest of bone marrow aspirate from
the right posterior-superior iliac crest for use in fusion and
Local autograft for arthrodesis. He lost 2 liters of blood but
had no hemodynamic issues, post op he remained intubated and was
transferred to the ICU for close monitoring. He did require 4 u
PRBC intra-op and recieved more transfusions post op. He was
extubated on post op day #1. He had JP drain in which was
monitored and was removed post op day #2. His foley was also
removed POD#2. He was OOB POD#2 and transferred to the floor.
Pt consult was obtained and felt appropriate for rehab.Diet was
advanced.Incision was clean and dry with staples.
Medications on Admission:
metoprolol XL 50MG; lisinopril 5mg; neurontin 300mg; lipitor
40mg; oxycontin 40mg; dilaudis 4mg prn; percocet 1tab prn; xanax
0.25mg; glycolax, timoptic eye gtts, ASA.
Discharge Medications:
1. Lisinopril 5 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): take while on narcotics.
Disp:*60 Capsule(s)* Refills:*1*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Polyethylene Glycol 3350 17 g (100%) Powder in Packet Sig:
One (1) Powder in Packet PO daily ().
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
7. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
Eagle [**Hospital **] Rehabilitation Center - [**Location 23723**]
Discharge Diagnosis:
Metastatic spine mass
post op anemia
melanoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Shower daily. Okay to get incision wet but do not immerse
incision in water until follow up.
?????? Do not smoke
?????? No tub baths or pools until seen in follow up.
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
Staple removal should occur 14 days post op ([**2113-4-3**]) - at rehab
or call [**Telephone/Fax (1) 2992**] for appt. Follow up with Dr. [**Last Name (STitle) 548**] in 6
weeks with xrays call [**Telephone/Fax (1) 2992**] for appt.
Completed by:[**2113-3-24**]
|
[
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"600.01",
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"338.3",
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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4842, 4935
|
2272, 3449
|
329, 788
|
5025, 5049
|
2004, 2249
|
6261, 6526
|
1659, 1676
|
3671, 4819
|
4956, 5004
|
3475, 3648
|
5073, 6238
|
1691, 1985
|
280, 291
|
816, 1383
|
1405, 1563
|
1579, 1643
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,211
| 155,097
|
41060
|
Discharge summary
|
report
|
Admission Date: [**2198-2-7**] Discharge Date: [**2198-2-14**]
Date of Birth: [**2146-7-28**] Sex: M
Service: MEDICINE
Allergies:
Peanut / compazine / Hydrocodone / Zocor / Gemfibrozil
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Back pain, SOB
Major Surgical or Invasive Procedure:
Bronchoscopy [**2198-2-7**] - tracheal stent was removed, microtear in
mucosa was noticed. Stent not replaced.
Bronchoscopy [**2198-2-14**] - microtear showed evidence of healing.
Stent not placed.
History of Present Illness:
The patient is a 51 yo M with a hx of asthma, CAD s/p CABG, DMI,
tracheobronchomalacia, who underwent bronchoscopy with tracheal
stent placement on Monday ([**1-30**]) by Dr. [**Last Name (STitle) **] at [**Hospital1 18**]. Patient
reports that since that time he has had worsening SOB as well as
back pain and worsened productive cough of mucus (no blood spots
or streaks). He also noted to have a wheezy chest. He called Dr. [**Name (NI) 89545**] office to inform him of these symptoms yesterday and
today, and then proceeded to [**Hospital1 **] ED, where he underwent CT
chest showing pneumomediastinum. He received 3 grams IV unasyn
and 12 mg IV morphine and fluconazole 100mg PO and was
transferred to [**Hospital1 18**] for further management.
.
In the ED, initial vs were: 98.7 100 157/76 18 100% 3L NC, pain
[**3-8**]. Labs were remarkable for leukocytosis to 13.9 with a left
shift. Patient was seen by IP in the ED, with a plan to undergo
bronchoscopy and likely stent removal this evening. He was
admitted to the medicine service for further management. Vitals
on transfer were HR 103, BP 153/85, 100% on 3L.
.
On the floor, his vitals were 101.8, BP 155/70, HR 80, RR 20,
O2Sat%98 on 3L NC. He reported significant diffuse back pain,
7/10 intensity. He also had some mild nausea, but denied SOB,
chest pain, dizziness, abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
-Type 1 DM- s/p pancreatic transplant [**2190**]
-CABG [**2186**]
-CHD with 5 stents placed [**2192**], stable angina
-Severe persistent asthma: PFTs done at [**Hospital1 498**] recently that did
not show an obstructive pattern, spirometry had normal flows and
lung volumes showed a mildly reduced TLC, there was a low DLCO
57% predicted.
-Allergic rhinitis
-Hx MRSA pneumonia
-severe food allergies (peanuts)
-OSA on CPAP 11 cmH2O
Social History:
Lives with his wife, no children.
Occupation: long term disability.
Smoking history: denies.
Alcohol: occasional.
He has a dog at home and denies allergies to dogs
Family History:
Noncontributory
Physical Exam:
On admission:
-------------
Vitals: T101.8, BP 155/70, HR 80, RR 20, O2Sat%98 on 3L NC.
General: Alert, orientedx3, in slight distress, labored
breathing, connected to oxygen, on IV fluids
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse insp and exp sounds all over the lung bilaterally
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur, no
rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
bilateral pitting edema. Amputated Right big toe
on discharge:
-------------
Vitals: T98.3, BP 154/84, HR 89, RR 15, O2sat 96% on RA
General: Alert, orientedx3, appears comfortable speaking
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: good air entry bilaterally. coarse scattered insp and exp
rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur, no
rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. no
pitting edema. Amputated Right big toe.
Pertinent Results:
On admission:
-------------
[**2198-2-7**] BLOOD WBC-13.9* Hgb-13.0* Hct-36.6* MCV-85 Plt Ct-170
[**2198-2-7**] BLOOD Neuts-85* Bands-3 Lymphs-4* Monos-8 Eos-0 Baso-0
Atyps-0 Metas-0 Myelos-0
[**2198-2-7**] BLOOD Glucose-123* UreaN-10 Creat-1.1 Na-137 K-3.5
Cl-100 HCO3-27 AnGap-14
[**2198-2-8**] BLOOD Calcium-8.2* Phos-1.8* Mg-1.5*
[**2198-2-8**] BLOOD Cortsol-9.7
[**2198-2-9**] BLOOD PT-14.5* PTT-27.9 INR(PT)-1.3*
[**2198-2-8**] BLOOD cTropnT-<0.01
[**2198-2-9**] BLOOD cTropnT-0.08*
[**2198-2-10**] BLOOD cTropnT-0.05*
[**2198-2-10**] BLOOD ALT-17 AST-29 LD(LDH)-230 AlkPhos-79 Amylase-22
TotBili-0.3
[**2198-2-10**] BLOOD Lipase-13
On discharge:
-------------
[**2198-2-12**] URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2198-2-12**] URINE RBC-130* WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1
[**2198-2-14**] BLOOD WBC-6.2 Hgb-11.2* Hct-33.4* MCV-89 Plt Ct-320
[**2198-2-14**] BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-141 K-3.1*
Cl-103 HCO3-30 AnGap-11
[**2198-2-14**] BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
Microbiology:
-------------
[**2198-2-7**] BLOOD CULTURE **FINAL REPORT [**2198-2-13**]** NO GROWTH.
[**2198-2-7**] BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2198-2-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2198-2-10**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 315-7849S ON
[**2198-2-8**].
STAPH AUREUS COAG +. ~6OOO/ML. SECOND STRAIN.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 89546**],[**2198-2-8**].
ACID FAST SMEAR (Final [**2198-2-8**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2198-2-8**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
[**2198-2-7**] SPUTUM
GRAM STAIN (Final [**2198-2-8**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2198-2-11**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPH AUREUS COAG +. MODERATE GROWTH. STRAIN 2.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN-----------<=0.25 S R
ERYTHROMYCIN----------<=0.25 S =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S =>8 R
OXACILLIN------------- 0.5 S =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ <=0.5 S
ACID FAST SMEAR (Final [**2198-2-8**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2198-2-8**]):
PLEASE REFER TO SPECIMEN #315-7848S [**2198-2-7**].
PATIENT CREDITED.
[**2198-2-8**] & [**2198-2-10**] BLOOD CULTURE ** FINAL REPORT **: No Growth
[**2198-2-10**] SEROLOGY/BLOOD **FINAL REPORT [**2198-2-11**]**
CRYPTOCOCCAL ANTIGEN (Final [**2198-2-11**]): CRYPTOCOCCAL ANTIGEN
NOT DETECTED.
[**2198-2-10**] Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2198-2-14**]**
Respiratory Viral Culture (Final [**2198-2-14**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2198-2-11**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
[**2198-2-12**] URINE **FINAL REPORT [**2198-2-13**]**
URINE CULTURE (Final [**2198-2-13**]): <10,000 organisms/ml.
[**2198-2-13**] BRONCHOALVEOLAR LAVAGE Site: UPPER LOBE
RIGHT UPPER LOBE.
GRAM STAIN (Final [**2198-2-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2198-2-15**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2198-2-14**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2198-2-14**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2198-2-13**] Rapid Respiratory Viral Screen & Culture
Site: UPPER LOBE RIGHT UPPER LOBE.
**FINAL REPORT [**2198-2-16**]**
Respiratory Viral Culture (Final [**2198-2-16**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2198-2-16**]):
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Imaging:
--------
CXR portable AP [**2198-2-7**]:
Lung volumes are low. There is bibasilar
atelectasis. There is no pneumothorax or pleural effusions.
Cardiomediastinal silhouette is within normal limits. Patient is
status post CABG. Midline sternotomy wires are intact. Patient
status post ORIF of the left humerus, incompletely seen.
IMPRESSION: No acute intrathoracic process. Previously seen 4 mm
right lower lobe pulmonary nodule is not well seen on this study
since CT is more
sensitive and follow-up recommendation on the prior study
remains.
CXR portable AP [**2198-2-7**]:
The small amount of pneumomediastinum demonstrated on the
outside CT is below the threshold for detection on chest
radiograph, but no increase in
pneumomediastinum has been recently demonstrated. The lungs
demonstrate mild degree of pulmonary edema accompanied by small
amount of bilateral pleural effusion. Surgical clips related to
prior resection of the tumor are unchanged.
CXR portable AP [**2198-2-8**]:
FINDINGS: AP single view of the chest has been obtained with
patient in
sitting semi-upright position. Analysis is performed in direct
comparison
with the next preceding similar study dated [**2198-2-7**].
Patient is
status post sternotomy. Mild cardiac enlargement is present.
Presence of
multiple surgical clips in the left mediastinum are indicative
of previous
bypass surgery. The pulmonary vasculature is not congested and
the lateral
pleural sinuses remain free. There is a linear plate atelectasis
on the left lung base, but no other evidence of significant
pulmonary abnormalities is present. No signs of pneumothorax in
the apical area. When comparison is made with the next preceding
chest examination the at that time rather congested appearance
of the pulmonary vasculature has normalized. No new parenchymal
abnormalities have developed and the previously suspected
bilateral pleural effusions on the bases cannot be supported by
today's single AP chest examination.
CXR portable AP [**2198-2-9**]:
IMPRESSION: Worsening pulmonary edema superimposed on developing
pneumonia.
CXR portable AP [**2198-2-10**]:
IMPRESSION: Worsened right upper lung infiltrate.
CXR portable AP [**2198-2-11**]:
FINDINGS: There continues to be mild cardiomegaly. Post-CABG
changes are
again seen with sternotomy wires and mediastinal clips. There is
a dense
right upper lobe infiltrate and a patchy left lower lobe
infiltrate. There is mild pulmonary vascular redistribution.
Compared to the prior study, the
right upper lobe infiltrate is slightly more dense.
CXR portable AP [**2198-2-13**]:
1. Right-sided PICC line at the mid SVC. Finding communicated
with [**Doctor Last Name 501**]
on the IV team at 10 a.m. on [**2198-2-13**].
2. Minimal improvement in pulmonary edema and right upper
pneumonia.
CT TRACHEA W/O C W/3D R from OSH: ? pneumomediastinum
CT TRACHEA W/O C W/3D R [**2198-2-12**]:
IMPRESSION:
1). Interval development of diffuse ground-glass opacities most
prominent
within the right upper and lower lobes with additional opacities
noted in the lingula and left lower lobe consistent with
multifocal pneumonia. Small
bilateral pleural effusions, likely reactive in nature.
2). Severe tracheobronchomalacia, unchanged from [**2198-1-23**], with
interval
removal of a tracheal stent compared to [**2198-2-7**]. No evidence of
pneumomediastinum.
3). Stable 4-mm ground-glass nodule in the right upper lobe. As
previously
recommended, in the absence of risk factors, a repeat chest CT
in 12 months is indicated. If there are risk factors for
malignancy, a six-month followup may be obtained.
Brief Hospital Course:
51 yo M with a history of asthma, CAD s/p CABG, DM type I s/p
pancreatic transplant, tracheobronchomalacia, who underwent
bronchoscopy with tracheal stent placement on [**2198-1-30**] by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**] was transferred from Outside hospital due to
pneumomediastinum on CT Chest as well as likely HAP.
.
# Pneumonia: He's a pancreatic transplant patient on
immunosuppresants who had bronchoscopy on [**1-30**], following which
he started to feel feverish with chills. T measured once at home
that was 98.6. On admission, he was febrile with T of 102.4
along with leukocytosis and left shift. CXR showed infiltrate at
right lung base. He was started on vancomycin,cefepime,
ciprofloxacin and flagyl while sputum, blood and BAL cultures
were still pending. Standing dose of nebulizers (albuterol and
atrovent) were given as well as his baseline prednisone dose of
5mg once daily. His home asthma medications were continued while
in hospital. His general condition deteriorated further on the
morning of second day of admission (sepsis like picture and
respiratory distress), which made it necessary to transfer him
to the medical ICU. In the ICU his antiobiotics were changed to
vancomycin, meronem and micafungin. His ICU stay was complicated
by pulmonary edema due to fluid overload that responded well to
diuretics. Also, he was delirious the night before he was
transferred back to the medical floor and he pulled his own
foley's catheter at that time. His delirium was thought to be
due to IV morphine he received in the ICU. CPAP was initially
held due to question of pneumomediastinum and pneumonia. However
in the ICU, CPAP at 11 cm H2O was started with good response.
His microbiology studies of sputum and BAL showed MSSA and MRSA.
During his stay in the ICU, his fever subsided and his
leukocytosis trended down back to normal. In the ICU, his random
serum cortisol level was considered low (9.7). IV hydrocrot was
started with shift to prednisone and gradual taper (in 7 days)
back to 5 mg once daily, which is his baseline steroid use.
After he was transferred to the medical floor, he had a few
episodes of terminal hematuria due to the traumatic self-pull of
his foley's catheter while he was confused in the ICU. However,
this subsided on the discharge day. Overall during his stay, his
oxygen requirements decreased, breathing dramatically improved
and his fever and leukocytosis subsided. ID team was consulted
at admission and was following the patient during his stay. PICC
line was placed on [**2198-2-13**] and position confirmed by CXR. He was
discharged with it to complete IV vancomycin for total of 3
weeks.
.
# Pneumomediastinum: He had tracheal stent for
tracheobronchomalacia on [**2198-1-30**], following which he started to
have back pain and worsening of his SOB. CT chest at outside
hospital showed quesitonable pneumomediastinum, that is
confirmed by the chest radiologist here verbally without formal
report. He was evaluated and seen by IP who did rigid
bronchoscopy in the OR for him on [**2198-2-7**] night. Stent was
removed and there was possible microperforation in the medial
aspect of the left main stem. His repeat CT trachea on [**2198-2-12**]
showed no pneumomediastinum. He had repeat bronchoscopy on
[**2198-2-13**] which showed that the microtear seen on the prior
bronchoscopy is healing. Stent was not placed.
.
# pancreatic transplant: Transplant team was following him up
during his stay. His predinisone, tacrolimus and mycophenolate
mofetil were continued while in hospital.
.
# CAD s/p CABG: He had CABG in [**2186**] with 5 stents placed in
[**2192**]. He has stable angina, last episode of chest pain was a
week prior to presentation, on effort. His aspirin, plavix and
simvastatin were continued while in hospital. His isosorbide
mononitrate and metoprolol were initially held due to his septic
condition. After stabilizing him and seeing some improvement in
his overall health status, these medications were resumed.
.
# Severe persistent asthma: His home medications were continued
in addition to standing doses of albuterol and atrovent
nebulizers while in hospital.
# mild hypokalemia: most likely related to nutrition - patient
reports eats banana/[**Location (un) 2452**] juice at home but not while in the
hospital. Patient was encouraged to increase K [**Doctor First Name **] products.
The visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 8757**] to check his K level 2 days
following discharge.
Medications on Admission:
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
Montelukast Sodium 10 mg PO DAILY
Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea or wheeze
Tiotropium Bromide 1 CAP IH DAILY
Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Metoprolol Tartrate 25 mg PO BID
Simvastatin 20 mg PO DAILY
Fish Oil (Omega 3) 1000 mg PO DAILY
Aspirin 325 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Clonazepam 0.25 mg PO TID PRN Anxiety
Duloxetine 180 mg PO DAILY
Ezetimibe 10 mg PO DAILY
Fexofenadine 180 mg PO BID
Omeprazole 20 mg PO DAILY
Ranitidine 150 mg PO BID
Tacrolimus 2 mg PO Q12H
Mycophenolate Mofetil 750 mg PO BID
PredniSONE 5 mg PO DAILY
Tamsulosin 0.4 mg PO HS
traZODONE 100 mg PO HS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary:
- MRSA Pneumonia
- Tracheal tear c/b pneumomediastinum
- Traumatic foley, c/b hematuria
Secondary:
- Tracheobronchomalacia
- Multi-vessel CAD s/p CABG [**2186**]
- PCI-stent x 5
- DM type I
- S/P pancreas tranplant
- Severe persistent asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Full Code.
Discharge Instructions:
Dear Mr [**Known lastname 9995**],
You were admitted to [**Hospital1 18**] due to small pockets of air around
your main airway and infection in your lung (pneumonia). Your
main airway was checked through a scope on admission. During the
scope, the tracheal stent was removed and a small tear in the
lining of your main airway was noted. The stent was not
replaced. For your lung infection you were given strong IV
antibiotics, nebulizers, higher doses of steroids compared to
your baseline in addition to your immunosupprestants.
However, because your general health condition deteriorated, you
were admitted to the medical ICU. You were continued on IV
antibiotics during your stay. You had some increase of fluid in
your lungs which responded well to diuretics.
You did well during your stay in the ICU, and you were
transferred back to the medical floor where your antibiotics,
nebulizers, steroid and immunosupprestants were continued.
Overall during your stay your general condition and breathing
dramatically improved.
Before being discharged, you had another scope to evaluate the
small tear in your main airway, which showed that the small tear
is healing. Stent was not replaced.
You had a PICC line placed so you can get your IV antibiotic
(VANCOMYCIN) through it, since giving this antibiotic through
peripheral line is irritating to the skin.
Your potassium was low during you stay. You should eat bananas,
[**Location (un) 2452**] juice, foods that are [**Doctor First Name **] in potassium. Your potassium
will be checked by the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] and if
continues to be low you may need replacement. Low potassium can
cause cardiac arrhythmia so it is important that it is
re-checked.
The following changes are done for your medications:
- START Prednisone 20 mg once daily tomorrow [**2198-2-15**] THEN
START Prednisone 10 mg once daily for 2 days ([**2-16**] and [**2-17**])
THEN
CONTINUE your baseline Prednisone 5 mg once daily.
- START Vancomycin IV 1000mg twice daily for 14 days after your
discharge day (total 3 weeks)
- CONTINUE the rest of your medications
Please follow up with your appointments as highlighted below:
Followup Instructions:
Regarding your IV antibiotics:
Department: INFECTIOUS DISEASE
When: MONDAY [**2198-2-26**] at 11:00 AM [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: [**Hospital Ward Name **] [**2198-3-16**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Schedule an apppointment with your primary care doctor in [**12-31**]
weeks and your transplant doctor in 2 weeks.
Completed by:[**2198-2-20**]
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59,198
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Discharge summary
|
report
|
Admission Date: [**2194-3-25**] Discharge Date: [**2194-3-29**]
Date of Birth: [**2135-12-13**] Sex: M
Service: MEDICINE
Allergies:
Tetanus
Attending:[**Last Name (un) 11974**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
Pulmonary vein isolation ablation [**2194-3-25**]
DCCV [**2194-3-29**]
History of Present Illness:
58 yo man with nonischemic cardiomyopathy and paroxysmal atrial
fibrillation who presented [**12/2193**] to [**Hospital6 3105**]
with palpitations. Atrial fibrillation with RVR (120) was
treated and converted with IV diltiazem. Sotalol was increased.
Subsequent testing indicated LVEF 53% by echocardiogram, ETT
showed mild anterior septal wall ischemia. Cardiac
catheterization was negative for epicardial coronary artery
disease. At cardiology follow up with Dr. [**Last Name (STitle) **] [**2194-1-10**] recurrent
PAF was identified and elective admission for planned PVI
scheduled for today.
Past Medical History:
Paroxysmal atrial fibrillation
Nonischemic cardiomyopathy
s/p CRT-D St. [**Male First Name (un) 923**] '[**92**] for EF of 25-30%, with subsequent
improvement of EF 45% with [**Hospital1 **]-V pacing
Class II-III CHF in setting of atrial fibrillation
Congenital bicuspid aortic valve
s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] procedure '[**78**] at CMC
Aortic aneurysm
s/p arch replacement with reimplantation of right
coronary artery and closure of PFO '[**88**] at CMC
COPD
Hypothyroidism
Chronic neck and back pain
S/P multiple blood transfusions
Renal calculi
Depression
s/p hernia repair
s/p left testicular surgery
s/p left shoulder surgery
s/p left knee arthroscopy
s/p perforated bowel (remote)
Social History:
Single, one child age 19. Lives alone, disabled
Stopped smoking '[**90**]. Prior ETOH abuse > 27 years
Family History:
Negative for premature CAD, cardiomyopathy, or SCD
Physical Exam:
Patient arrives to CCU s/p PVI ablation intubated.
VS 98.4 HR 72 SR BP 102/58 Tele AV paced
General: intubated
HEENT: PERRL. Conjunctiva pink, no pallor or cyanosis of oral
mucosa
NECK: Supple with JVP not visualized
CARDIAC: PMI located in 5th ICS, midclavicular line. RR, normal
S1 S2 2/6 SEM heard loudest in LLSB. No thrills, lifts. No S3 or
S4
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Intubated, CTAB, no crackles, wheezes or rhonchi in anterior
lung fields
ABDOMEN: Soft. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominal bruits
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexor/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle
PULSES:
Right: carotid 2+ femoral 2+ popliteal 2+ DP 2+ PT 2+
Left: carotid 2+ femoral 2+ popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2194-3-25**] 06:56PM GLUCOSE-104* UREA N-9 CREAT-1.0 SODIUM-142
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
CALCIUM-8.4 PHOSPHATE-4.6* MAGNESIUM-1.9
[**2194-3-25**] 06:56PM PT-26.2* INR(PT)-2.5*
[**2194-3-25**] 09:00AM WBC-5.8 RBC-3.73* HGB-13.2* HCT-36.9* MCV-99*
MCH-35.5* MCHC-35.9* RDW-13.2 PLT COUNT-168
Brief Hospital Course:
#1 Atrial fibrillation
On [**2194-3-25**] successful PVI under the direction of Dr. [**Last Name (STitle) **].
Immediate post procedure care required transfer to the CCU for
ongoing respiratory suppport in the setting of requiring high
dose propofol for intraop ventilation via high flow jet
ventillation and for IV diuresis in setting of periprocedure IVF
5L.
Post PVI telemetry monitoring showed NSR with A-V and BiV
pacing. On [**3-28**] interrogation of ICD/BiV pacemaker device
identified persistent atrial tacycardia. He remained
hemodynamically. He underwent cardioversion initially with 200J
external
biphasic energy without conversion, and shocked again with 300J
external biphasic energy with prompt return of sinus rhythm.
#2 Nonischemic cardiomyopathy
Acute on chronic systolic heart failure in the setting of 5L IVF
intraop PVI. He was diuresed by lasix drip, transitioned to [**Hospital1 **]
po lasix reaching his pre admission dose of 80 mg qAM and 40 mg
qPM by day of discharge.
#3 Anticoagulation
Coumadin dosing continued daily. INRs therapeutic at 3.0
#4 COPD
Clinically stable. At baseline he uses O2 prn dyspnea. Inhalers
continued.
#5 HTN
Lisinopril was held during this admission due to SBP 90-low 100s
during diuresis. At day of discharge SBP trending towards 110
but not consistent to alllow restarting lisinopril.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - as needed
BUDESONIDE-FORMOTEROL [SYMBICORT] - 80 mcg-4.5 mcg/Actuation HFA
Aerosol Inhaler - 2 inhaled twice a day
CYCLOBENZAPRINE - 10 mg Tablet: 1 Tab TID as needed for back
pain
DIGOXIN - 125 mcg Tablet - 1 Tab once a day
FUROSEMIDE - 40 mg Tablet - 2 Tabs every morning, one tablet
every evening
GABAPENTIN - 300 mg Capsule - 1 Cap TID as needed for PRN back
pain
LISINOPRIL - 5 mg Tablet - 1 Tab once a day
OXYGEN AS NEEDED AT NIGHT
POTASSIUM CHLORIDE [KLOR-CON M20]- 20 mEq Tablet, ER
Particles/Crystals - 2 Tabs
mouth once a day
SIMVASTATIN - 20 mg Tablet - 1 Tab once a day
SOTALOL - 120 mg Tablet - 1 Tab twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 inhaled once a day
WARFARIN - 5 mg Tablet - 1 Tab once a day (PM)
Medications - OTC
ASPIRIN - 81 mg Tablet - 1 Tab once a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet - 1 Tab once a
day
FOLIC ACID - 0.4 mg Tablet - 1 Tab once a day
MAGNESIUM OXIDE - 400 mg Tablet - 1 Tab twice a day
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for pain.
3. sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day.
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
8. Symbicort 80-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
9. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for back pain.
10. furosemide 40 mg Tablet Sig: Two (2) Tablet PO in the
morning: then take one tab in the evening.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: DO
NOT restart this medicine until Dr [**First Name (STitle) 3646**] reviews your blood
pressures.
12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation once a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 1 months.
14. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
16. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: x1 month after
daily.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Atrial fibrillation
Non ischemic cardiomyopathy
Chronic systolic heart failure LVEF 45%
s/p CRT-D biV ICD [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] '[**92**]
Bicuspid aortic valve, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] '[**78**]
Aortic aneurysm s/p arch replacement with reimplantation right
coronary artery and closure PFO '[**88**]
COPD
Discharge Condition:
58yo with NICMP LVEF 45%, PAF, COPD, referred for PVI due to
increasinly symptomatic Afib. Procedure performed [**3-25**] under the
direction of Dr [**Last Name (STitle) **]. Post procedure recovery significant for
acute on chronic CHF due to IVF requirements periprocedure. He
responded to IV diuresis. Lisinopril held due to hypotension
with SBPs 90-100.
PEx
VS 90-110/70 tele SR biV paced HR 60s
Lungs CTA
Heart RRR -MRG
PV both fem access sites - bleed or bruit
labs [**2194-3-28**]: INR 3.0 K 3.5 crea 0.7
Mental Status: Clear and coherent. Level of Consciousness: Alert
and interactive. Activity Status: Ambulatory - Independent.
Plan
#1 PAF
s/p PVI [**3-25**], s/p DCCV [**3-29**]
cont coumadin as per Dr[**Name (NI) 33902**] instructions
Cont sotalol 120mg [**Hospital1 **]
Continue aspirin 325 mg once a day x 1 month
Adding omeprazole 20 mg once a day x 1 month
KOH monitoring as instructed
f/u Dr [**Last Name (STitle) **] as above
#2 Chronic systolic HF
NICMP EF 45%-50%
Resume [**Hospital1 **] lasix dosing
Lisinopril on hold due to hypotension-reevaluate as outpatient.
Continue digoxin
f/u Dr [**First Name (STitle) 3646**] as above
#3 COPD
Cont inhalers, PRN O2
#4 HLP
Cont simvastatin
Discharge Instructions:
You had a procedure to treat atrial fibrillation called
pulmonary vein ablation.
Your discharge was delayed because you required intravenous
medicine to help your body get rid of excees intravenous fluid
that was required during the ablation procedure.
Activity restrictions and groin site care as per discharge
instructions
Continue coumadin at 3 mg once a day. Dr [**First Name (STitle) 3646**] requests an INR
be done Wednesday morning. He will give you results when you see
him in the office Wednesday [**4-2**] at 3:15
Record and transmit your heart rhythm using the [**Doctor Last Name **] of Hearts
monitor as instructed. You will be told about any concerning
recordings.
During device interrogation on [**3-28**] it was noted that atrial
fibrillation was present. You had successful cardioversion on
[**3-29**].
Followup Instructions:
Dr [**First Name (STitle) 3646**] [**4-2**] at 3:15
Coumadin level to be done the morning of [**4-2**] and will be
reviewed by Dr [**First Name (STitle) 3646**] at afternoon appointment.
Department: CARDIAC SERVICES
When: TUESDAY [**2194-4-1**] at 11:00 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
Department: CARDIAC SERVICES
When: FRIDAY [**2194-4-25**] at 10:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2194-5-16**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
Completed by:[**2194-4-2**]
|
[
"311",
"428.0",
"V45.02",
"338.29",
"V45.89",
"428.23",
"427.31",
"401.9",
"V46.2",
"V15.82",
"V13.01",
"425.4",
"V42.2",
"244.9",
"427.32",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.28",
"99.61",
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
7272, 7321
|
3208, 4554
|
281, 354
|
7753, 8268
|
2856, 3185
|
9836, 10888
|
1875, 1927
|
5689, 7249
|
7342, 7732
|
4580, 5666
|
8987, 9813
|
1942, 2837
|
229, 243
|
382, 979
|
8283, 8962
|
1001, 1738
|
1754, 1859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,887
| 163,359
|
15095
|
Discharge summary
|
report
|
Admission Date: [**2138-11-20**] Discharge Date: [**2138-11-26**]
Date of Birth: [**2077-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
L 2nd and 3rd toe debridement
History of Present Illness:
Mr. [**Known lastname 44065**] is a 60 year-old man with a history of chronic lower
extremity venous stasis complicated by chronic cellulitis,
cerebral palsy, atrial flutter s/p recent cardioversion,
presenting with cellulitis. He was recently admitted to [**Hospital1 18**]
[**10-24**] - [**10-28**] with toe cellulitis. He was treated with
antibiotics and discharge [**10-28**] to [**Hospital3 **] for skilled
wound care. On [**11-6**] he was discharged to home. Since then, he
has had increasing leg erythema, pain, and weeping. He denies
fevers, chills. He also denies palpitations or light-headedness.
He saw Dr. [**Last Name (STitle) 2392**] [**11-12**] who noted worsening leg appearance, but
the patient refused hospitalization for IV antibiotics. His home
nurse has also been urging him to go to the hospital. Finally,
because the pain was worsening yesterday, he presented to the
ED.
.
In the ED, initial vs were: T 97.6, HR 94, BP 116/88, RR 16, O2
100% RA. The impression was lower extremity cellulitis. He was
given a dose of vancomycin 1g and morphine 6 mg with plans to
admit to medicine. However, overnight he was persistently tachy
to 120s, briefly hypotensive with systolic to the 70s, and did
not receive fluids. In the morning he was given a total of 4 L
NS , and antibiotics were broadened to include
piperacillin-tazobactam. HR fell to 90s-110s (sinus, with ST
depressions thought to be rate-related). Blood pressure rose to
96/60.
.
On arrival to the floor, the patient complains of ongoing leg
pain. He denies chest pain, palpitations, shortness of breath.
He also denies nausea, vomitting, chills. Review of systems
otherwise negative
Past Medical History:
- Cerebral palsy, wheelchair bound as of ~[**2130**]
- History of PEs (bilateral in [**12/2134**], right subsegmental in
[**8-/2138**]) on anticoagulation
- A-flutter s/p cardioversion [**10-2**], on amiodarone and
anticoagulated
- HTN
- Right heart failure with moderate Pulmonary hypertension, 2+
TR on TTE (but done in the setting of PE [**8-/2138**])
- Hypothyroidism
- h/o recurrent MRSA cellulitis
- Incontinence
- Cervical spondylosis
- Chronic back pain
- Obesity
- Hyperlipidemia
- Chronic venous insufficiency
- Depression
- Open heart surgery at age 12, unknown type of repair (patent
foramen ovale or ventricular septal defect?)
- Hematuria w/ atypical cells [**8-/2138**]
Social History:
He was discharged to [**Hospital3 2558**] after his recent admission
but then discharged to home [**11-6**] with 8 AM to 5 PM home
services. There is considerable concern on the part of his PCP
that he may not have adequate services at home. He had prior
admission for abuse from previous caregiver. [**Name (NI) **] uses an electric
wheel chair to move about. He smomked 1 ppd for 10 years, quit
in [**2128**]. He drinks alcohol occasionally and denies illicit
drugs. He denies having any living family
Family History:
Mother died at 48 from brain tumor. Sister died at 42 from
breast cancer. No premature CAD of sudden cardiac death
Physical Exam:
On admission:
VS: T 96.5, BP 93/56, HR 113, RR 29, O2 99% 2L
Gen: alert, oriented, conversant
Cardiac: faint systolic murmur, regular, tachycardic
Lungs: clear bilaterally
Abd: soft, nontender, obese
Ext: L arm contracted. Bilateral lower extremity woody
induration below the knee with erythema extending both
proximally and distally, areas are denuded, other areas black
and necrotic appearing, entire leg weaping desquamating skin,
bilateral 2+ pitting edema, all warm and exquisitely tender.
Distal pulses palpable. Sensation intact.
.
On discharge:
Legs still with breakdown bilaterally, however, erythema has
resolved. No pustular drainage.
Pertinent Results:
Admission labs:
[**2138-11-20**] 01:35PM NEUTS-85* BANDS-8* LYMPHS-3* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2138-11-20**] 01:35PM WBC-15.5* RBC-3.95* HGB-10.9* HCT-32.2*
MCV-82 MCH-27.7 MCHC-33.9 RDW-14.9
[**2138-11-20**] 01:35PM TSH-12*
[**2138-11-20**] 01:35PM GLUCOSE-167* UREA N-7 CREAT-0.6 SODIUM-133
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-11
.
[**11-20**] blood cultures: no growth
.
[**11-23**] RUE Doppler negative
.
[**11-20**] wound culture: MRSA
.
[**11-20**] CXR: no focal pneumonia
Brief Hospital Course:
A 60 year-old man with a history of chronic venous stasis
complicated by chronic lower extremity cellulitis, cerebral
palsy, atrial flutter, currently admitted for cellulitis.
.
#. Cellulitis: He had impressive lower extremity erythema and
sloughing of skin. Although it is difficult to know what his
legs look like chronically, prior notes document mostly just
woody induration without significant erythema. The sloughing and
necrotic-appearing areas also seem to be new. The only bacteria
that has been isolated previously was MRSA from a wound. Blood
pressures were on the low end of what they have been previously
and he persisted with sinus tachycardia depite many fluid
boluses. Boluses were continued in the MICU. He was given
vancomycin and Zosyn, with dramatic improvement in the lower
extremity erythema over the first day. He was given morphine IV
for pain prior to wound care; oxycontin was started for
long-acting control and oxycodone for breakthrough pain. Blood
cultures were negative. Wound culture grew MRSA. Zosyn was
discontinued and Vancomycin was continued to complete a 14-day
course. Wound care recommendations were followed and dressings
were changed each day. Legs were kept elevated. The erythema
resolved though on discharge, there was still a moderate degree
of skin breakdown. On the days prior to discharge the posterior
surfaces of his calves developed significant bleeding from wound
beds. His hematocrit remained stable. Vascular was consulted and
they were unable to identify any actively bleeding vessels. His
dressings are to be changed per vascular/wound care
reccomendations.
.
# ? DM: FS 422 on admission with history "borderline" diabetes
(HgA1c 6.3% in 08/[**2138**]). BG may be elevated in the setting of
stress currently. He was given humalog insulin sliding scale.
Blood sugars improved and SSI was discontinued.
.
#. Atrial Flutter: Pt with history of a-flutter but had
cardioversion done in late [**2138-8-3**] and is on amiodarone.
Currently EKGs all appear to be sinus. Amiodarone and
anticoagulation were continued. Patient remained in NSR.
.
#. Cerebral palsy: Patient increasingly unable to perform ADLs.
Baclofen was continued. He will likely need arrangements for
more home services vs long-term care facility prior to
discharge.
.
#. Hypothyroidism: TSH was 11. Levothyroxine 75 mcg daily was
continued.
.
#. History of Pulmonary Embolism: Anticoagulation was initially
held due to high INR in the setting of antibiotics. Coumadin was
restarted on the floor. On day of discharge his INR was 1.7. He
shoudl have his INR followed closely as an outpatient.
.
# ? CHF: Patient with recent clinical and echo diagnosis of
R-sided CHF, but that was in the setting of acute pulmonary
embolism. There are also mentions in prior notes of diastolic
heart failure, although this is not evidenced on his echos. He
is on a heart failure regimen at home. Torsemide,
spironolactone, and metoprolol were initially held in the
setting of borderline blood pressures. Metoprolol was restarted
this AM prior to transfer to the floor. Spironolactone was also
restarted.
.
# ST depressions: likely rate-related. Troponin not elevated.
Repeat EKG back to baseline.
Medications on Admission:
baclofen 20 mg TID
lovastatin 40 mg daily
levothyroxine 75 mcg daily
hydrocodone-acetaminophen 5-500 mg q6h prn
spironolactone 25 mg daily
torsemide 20 mg daily
docusate 100 mg [**Hospital1 **]
amiodarone 200 mg daily
metoprolol 50 mg [**Hospital1 **]
miconazole powder [**Hospital1 **] prn
warfarin 5 mg daily
triamcinolone acetonide .1% [**Hospital1 **]
ASA 81 mg daily
Discharge Medications:
1. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical
twice a day as needed for fungal rash.
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily).
14. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): Hold
for respiratory depression/sedation -> started this
hospitalization due to leg pain. D/c once legs begin healing.
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for breakthrough pain.
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 8H (Every 8 Hours) for 9 days: Last day [**2138-11-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
MRSA Cellulitis
Hypotension
.
Secondary:
Cerebral palsy
h/o PE on coumadin
Aflutter s/p cardioversion
Right heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive - sometimes
lethargic
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 44065**],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted for infection in your legs and
you were also found to have low blood pressure requiring brief
care in the intensive care unit. For your leg infection, we
treated you with antibiotics and you will complete a 14-day
course. We also performed aggressive wound care on your legs to
help keep the wounds clean and dry.
.
We made the following changes to your medication:
We STARTED Vancomycin - 1 g every 8 hours for leg infection to
be taken for 9 more days - last day is [**12-5**].
We CONTINUED Coumadin - it is important for you to have your INR
routinely checked.
We STOPPED torsemide because of low blood pressure - this
medication may need restarted if you begin to have more swelling
in your legs or abdomen
We STARTED oxycontin and oxycodone for pain -> these are very
powerful pain medications and you should take the lowest
possible dose necessary. This medications should be weaned when
your legs begin to heal.
.
You should follow-up with Dr. [**Last Name (STitle) 2392**] once you are discharged
from rehab.
.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Appt: We are working on a follow up appt for you within the
next few weeks. The office will call you at home with an appt.
If you dont hear from them by tomorrow, please call them
directly to book an appt at number above.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
[
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"278.00",
"995.91",
"707.12",
"V15.1",
"327.23",
"V15.41",
"783.7",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9856, 9927
|
4643, 7853
|
327, 358
|
10102, 10102
|
4093, 4093
|
11455, 12091
|
3295, 3411
|
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|
9948, 10081
|
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|
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|
3426, 3426
|
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|
279, 289
|
386, 2048
|
4109, 4620
|
3440, 3965
|
10117, 10275
|
2070, 2757
|
2773, 3278
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,013
| 174,375
|
2163+55357
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-6-10**] Discharge Date: [**2129-6-25**]
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: This 88-year-old female with
coronary artery disease and left bundle branch block
presented with acute onset of dyspnea for 18 hours prior.
She was in her usual state of health, fairly sedentary and
able to ambulate about one block before developing chest
tightness and claudication, until the night before admission
when she developed progressive dyspnea at rest and was unable
to sleep. She had a cough, plus-minus fevers, and had to sit
upright to breath. She has a baseline four-pillow orthopnea.
She also reported chest tightness on the day of admission
similar to anginal pain in the past. The chest pain peaked
at noon on the day of admission. She called the emergency
medical technicians and presented to the Emergency
Department. There she was tachypneic with 30-40 respiratory
rate, oxygen saturation 100% on 4 liters face mask, and
tachycardiac to 120. Electrocardiogram showed left bundle
branch block. She was treated with aspirin, Lasix, Heparin,
and intravenous Nitroglycerin with mild improvement in her
symptoms. At 10:30 p.m. on the day of admission, she
developed acute decompensation with a respiratory rate of
40-50 and poor air movement. Her saturations remained at
100%. She was placed on BIPAP 10/5 with eventual respiratory
rate decrease to 30 after 10 minutes. She was then given
Albuterol nebulizers and oxygen via face mask with continued
improvement and was then admitted to the CCU for further
management.
PAST MEDICAL HISTORY: The past medical history revealed
coronary artery disease status post coronary artery bypass
graft in [**2121**]. Persantine Thallium study in [**10/2128**] was
normal. The patient has had left bundle branch block since
[**2124**]. There is a history of hypertension, chronic
obstructive pulmonary disease, positive PPD, pleural plaques
on chest x-ray in [**2125**], status post cholecystectomy, history
of pulmonary embolism, peripheral vascular disease with
claudication, chronic renal insufficiency with baseline of
[**12-13**].3, diabetes mellitus, and supraventricular tachycardia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Flovent, aspirin, Baycol,
Prilosec, Coumadin 3.5 mg q. day, Verapamil 80 mg t.i.d.,
Digoxin 0.125 mg q.o.d., iron, Atrovent, Lisinopril 40 mg q.
day, Imdur 30 mg q. day.
SOCIAL HISTORY: The patient is [**Location 11543**] and speaks
Portuguese.
PHYSICAL EXAMINATION: Blood pressure was 100/80, pulse 125
and regular, respiratory rate 30-40, O2 saturation 100% on 6
liters face mask. In general, the patient was an elderly,
ill-appearing female, tachypneic. HEENT examination revealed
normocephalic, atraumatic. Sclerae were anicteric. The
oropharynx was clear. The neck was full, JVP at 12 cm. The
chest revealed shallow breaths and wheezes, inspiratory much
greater than expiratory anteriorly. Cardiovascular
examination revealed tachycardia. No murmurs, gallops, or
rubs were appreciated. The abdomen was soft and nontender.
Bowel sounds were present. The extremities revealed 1+ edema
bilaterally halfway up to the knees. Neurologically, the
patient was alert and oriented but lethargic.
LABORATORY DATA: White blood cell count was 8.7, hematocrit
42, platelets 264,000. Differential revealed 61 polys, 29
lymphocytes, 4 monocytes, 3 eosinophils. Sodium was 142,
potassium 4.6, chloride 100, bicarbonate 27, BUN 16,
creatinine 1.3, glucose 195. Digoxin level was 0.4. PT was
18.8, PTT 27.9, INR 2.3, CK 51, troponin less than 0.05,
amylase 143, lipase 100. Electrocardiogram revealed sinus
tachycardia at 125 beats per minute, left bundle branch
block, no significant changes from prior of [**2126-6-18**]. Chest
x-ray revealed cardiomegaly, slight upper zone
redistribution, and pleural thickening in the left mid lung
field.
ASSESSMENT: This elderly female with coronary artery disease
and chronic obstructive pulmonary disease presented with
acute dyspnea at rest.
HOSPITAL COURSE
Cardiovascular: The patient was initially treated with
aspirin, Heparin, Nitroglycerin, and Digoxin, and her CKs
were cycled. No beta blocker was given at that time because
of her underlying chronic obstructive pulmonary disease.
Arterial blood gases were drawn to assess the pulmonary
status from the right femoral artery and she developed
hematoma at this site; however abdominal CT showed no
retroperitoneal bleed. During her hospital stay, there was
concern for mesenteric ischemia and her Digoxin was stopped.
In addition, her hospital course was complicated by multiple
episodes of chest pain of sudden onset with elevations in her
blood pressure to around 200 systolic with her heart rate in
the 140s. Her pain was relieved with sublingual
Nitroglycerin and on one occasion required morphine for
relief after sublinguals. Throughout all her episodes of
chest pain, she had no EKG changes and her CKs remained flat.
During one of her episodes of chest pain, a pain MIBI was
performed and showed no signs of ischemic change. Thus
cardiology concluded that her chest pain was not of cardiac
ischemic origin. Early in her hospital course, she remained
persistently tachycardiac in the 130s and 140s. She was
switched to Verapamil 120 mg q.i.d. and Isordil 80 mg t.i.d.
and eventually her baseline heart rate came down to the 70s
and 80s. However she still had occasional chest pain with
the elevated blood pressure and heart rate. There was a
question of whether her chest pain episodes were related to
meals; however no confirmation was obtained.
Pulmonary: Her initial presentation was consistent with
chronic obstructive pulmonary disease flare and she was
started on Albuterol, Solu-Medrol, and oxygen as well as
Levaquin. Her oxygen requirement was eventually weaned down
to her home baseline of 0.5 liters of oxygen per nasal
cannula and Prednisone was weaned during her hospital stay.
There was a question of whether her sinus tachycardia was
related to pulmonary embolism and D-dimer sent was negative.
However no VQ scan was performed because of her baseline
chest x-ray abnormalities. A pulmonary angiogram was not
done secondary to her baseline chronic renal insufficiency.
In addition, she was already on Heparin therapy and thus we
would not have changed our management.
Renal: The patient has a baseline chronic renal
insufficiency with a creatinine of 1.3 and thus all her
medications were renally dosed. She was hydrated before and
after angiography. There were no bumps in her creatinine
secondary to any dye loads.
Gastrointestinal: According to her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**], she has had multiple admissions in the past
for sudden onset chest pain and epigastric pain with
shortness of breath. She has also had intermittent
elevations in her amylase during these episodes which
eventually resolved in 12 to 48 hours. During this
admission, she had no episode of nausea, vomiting, or
diarrhea. She denied any postprandial pain, sitophobia, or
any weight loss. However her primary care physician wanted
to pursue a GI evaluation for her previous pain. An MRA that
was done at an outside hospital showed questionable
mesenteric stenosis and thus we proceeded to perform a
mesenteric angiogram while the patient was in-house. This
showed no significant stenoses. In addition, an MRCP was
also performed to evaluate for any pancreatic ductal
pathology and this showed ectatic pancreatic ducts with no
signs of obstruction. She remained guaiac negative with no
elevations of amylase or lipase during this admission. It
was recommended that she continue followup evaluation of her
symptoms as an outpatient.
Hematology: The patient was on Coumadin as an outpatient
which was stopped as she was supratherapeutic. She was
started on Heparin, however, will be discharged on Coumadin
and Lovenox subcutaneously until she is therapeutic. Iron
studies showed a microcytic anemia with a low absolute
reticulocyte count and thus she was started on iron therapy.
Endocrine: The patient was kept on NPH and regular insulin
sliding scale for her glucose intolerance.
Disposition: The patient will be discharged home with home
physical therapy services as well as VNA for her Lovenox
administration b.i.d. until her INR is therapeutic.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Chronic obstructive pulmonary disease
flare, chest pain, and abdominal pain of unknown etiology.
CODE STATUS: Full code.
DISCHARGE MEDICATIONS: NPH 10 units q.a.m. and 4 units
before dinner, Zestril 40 mg q. day, enteric coated aspirin
325 mg q. day, Combivent 120/21 mcg MDI 2 puffs b.i.d., iron
325 mg q. day, Lipitor 10 mg q. day, Prednisone 15 mg q. day
x 3 days starting [**2129-6-26**] and then 5 mg x 3 days starting
[**2129-6-29**], Verapamil 120 mg p.o. q.i.d., Isordil 10 mg p.o.
t.i.d., sublingual Nitroglycerin 0.3 mg sublingually p.r.n.
pain up to three doses, Coumadin 5 mg p.o. q. day, Lovenox 70
mg subq. b.i.d. until INR greater than or equal to 2.
DISCHARGE FOLLOWUP: The patient will follow up with her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], M.D. [**MD Number(1) 11525**]
Dictated By:[**Last Name (NamePattern1) 11544**]
MEDQUIST36
D: [**2129-6-25**] 10:50
T: [**2129-6-26**] 11:05
JOB#: [**Job Number **]
Name: [**Known lastname 1634**], [**Known firstname 1463**] Unit No: [**Numeric Identifier 1635**]
Admission Date: [**2129-6-10**] Discharge Date: [**2129-6-28**]
Date of Birth: [**2042-12-20**] Sex: F
Service: MEDICINE
This is an addendum to previously dictated discharge summary
from [**2129-6-10**].
Gastrointestinal: The patient presented with a history of
multiple admissions for sudden onset of chest pain and
epigastric pain associated with intermittent elevations in
amylase during these episodes, which eventually resolved in
12 to 48 hours. During this admission the patient had no
nausea, vomiting or diarrhea. In order to evaluate etiology
of abdominal pain the patient had KUB, abdominal ultrasound,
CT scan of the abdomen, mesenteric angiography and MRCP
performed, which were all negative. In addition, urine was
sent for ALA/PDA to rule out acute intermittent Porifera and
these tests were negative. In addition, the patient had a
urine bentiromide test sent to the laboratory and will follow
up with GI in two weeks from discharge for results of this
test. Etiology of the pain is unclear.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1636**], M.D. [**MD Number(1) 1637**]
Dictated By:[**Last Name (NamePattern1) 1638**]
MEDQUIST36
D: [**2128-12-17**] 09:36
T: [**2129-12-21**] 08:47
JOB#: [**Job Number 1639**]
|
[
"V15.82",
"427.89",
"491.21",
"V12.51",
"250.00",
"V45.81",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
8495, 8619
|
8643, 9166
|
2259, 2430
|
2530, 8410
|
9187, 11028
|
132, 1580
|
1603, 2232
|
2447, 2507
|
8435, 8473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,155
| 194,433
|
43938
|
Discharge summary
|
report
|
Admission Date: [**2151-10-7**] Discharge Date: [**2151-10-14**]
Date of Birth: [**2071-8-19**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 y.o. woman, 4 weeks s/p R total knee replacement, transferred
from [**Hospital3 537**] rehab for possible pneumonia. On arrival
found to be hypotensive down to 88/31. Blood pressure responded
to 2 liters NS fluid. Denies cough, shortness of breath,
subjective fevers. [**Month (only) 116**] have had a fever sometime last week
measured at [**Hospital1 **] but is unsure. Reports recent hospitalization in
[**Month (only) **] of this year for pneumonia which was treated with
antibiotics with good resolution. Patient's chief complaint is
crampy abdominal pain x 2 weeks, accompanied by vomiting and
diarrhea. Reports some relief of pain with both diarrhea and
vomiting. Estimates that she has been vomiting about 4 x/day.
No hematemesis, hematochezia, melana, BRBPR. Patient does have
hx of heartburn, for which she takes Prilosec. No recent travel
or new foods. Reports decreased appetite [**1-20**] fear of
exacerbating vomiting. Reports night sweats the night before
admission.
.
Briefly this is an 80 y/o female who is being transferred from
the MICU after admission following a code blue. The patient is
s/p left knee replacement X 4 weeks. The patient was originally
admitted for rehab for abd pain,diarrhea and pneumonia (received
CTX and azithromycin). Unclear as to whether or not stool
cultures were sent.
Per MICU note:
Called to see patient for code blue when resident found patient
with altered mental status, hypotension, and had difficulty
gaining access. Pt reportedly received 5 mg oxycodone 6 hours
prior to event. She was given 0.4 mg Narcan and then access was
lost. The patient maintained a HR 70-80s and RR 14 throughout
the code. BP at lowest was 46/31. With Trendelenberg improved to
82/38. 2 attempts were made for IV groin CVL without success.
RNs were successful at placing 2 peripheral large bore IVs and
IV fluid was started. Pt received 2 L NS with improvement in BP
to 97/37. Ten minutes after I entered the room( in midst of IV
access attempts), the patient began speaking and was more
responsive. Her overall color improved. This improvement in MS
seems related to narcan, but may also have been from
Trendelenberg and improvement in CNS perfusion with
Trendelenberg.
.
The patient is now clinically stable and is being transferred to
medicine.
Past Medical History:
ICD, mi, chf, dyspnea, copd, chronic congested cough, foot
neuropathy, arthritis, hypothyroid, cabg, cataracts, hernia
repair
Social History:
TOB-denies
EtOH-Denies
Family History:
NC
Physical Exam:
VS: T: BP:88/31 P: 80 R: 21 O2: 95%
GEN: elderly woman, NAD, breathing comfortably
HEENT: OP clear, dentures in place - pt refusing to remove them,
MMM
CV: RRR, 2/6 sem
PULM: Ronchi at BL lung bases
ABD: soft, NT, ND, +BS, no HSM
EXT: clean, well-healed surgical scar on R knee
NEURO: alert and oriented
Pertinent Results:
[**2151-10-8**] 12:00AM CK(CPK)-65
[**2151-10-8**] 12:00AM CK-MB-2 cTropnT-0.05*
[**2151-10-7**] 12:41PM LACTATE-2.5*
.
LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-10-14**] 04:55AM 7.0 3.06* 9.3* 28.4* 93 30.4 32.6 14.2
348
[**2151-10-13**] 01:05PM 30.6*
[**2151-10-13**] 05:08AM 8.0 2.72* 8.5* 26.0* 96 31.4 32.8 13.9
301
[**2151-10-12**] 05:00AM 12.7*# 3.31* 10.0* 31.1* 94 30.3 32.2
13.7 345
[**2151-10-11**] 05:22AM 7.5 2.89* 9.0* 27.6* 95 31.1 32.6 13.7
270
[**2151-10-10**] 05:22PM 31.1*
[**2151-10-10**] 05:20AM 7.1 3.10* 9.6* 29.2* 94 30.8 32.8 13.6
269
[**2151-10-9**] 11:21PM 25.8*
[**2151-10-9**] 05:52PM 9.2 2.89* 9.1* 27.8* 96 31.4 32.6 13.6
244
[**2151-10-9**] 01:28PM 11.9* 3.24* 10.1* 30.2* 93 31.2 33.6 13.8
278
[**2151-10-9**] 06:34AM 10.7 3.49* 10.8* 33.1* 95 30.9 32.7 13.7
273
[**2151-10-8**] 07:05AM 7.7 2.99* 9.3* 27.7* 93 31.1 33.6 13.8
216
[**2151-10-7**] 12:30PM 10.4 3.32* 10.5* 31.9* 96 31.7 33.1 13.8
248
[**2151-10-6**] 01:01PM 13.6* 3.61* 11.0* 33.8* 94 30.4 32.5 13.4
260
.
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2151-10-9**] 01:28PM 64.7 26.7 4.9 3.5 0.2
[**2151-10-7**] 12:30PM 72.2* 19.8 4.1 3.7 0.3
[**2151-10-6**] 01:01PM 80.5* 14.2* 3.2 1.7 0.4
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-10-14**] 04:55AM 89 13 1.2* 140 4.3 108 20*1 16
[**2151-10-13**] 05:08AM 96 15 1.1 140 4.6 113* 19*1 13
[**2151-10-12**] 05:00AM 120* 16 1.2* 141 3.7 109* 19*1 17
[**2151-10-11**] 05:22AM 89 17 1.0 138 3.7 111* 18*1 13
[**2151-10-10**] 05:20AM 89 18 1.3* 141 4.5 111* 20*1 15
[**2151-10-9**] 01:28PM 136* 20 1.4* 138 4.2 106 17*1 19
[**2151-10-9**] 06:34AM 91 22* 1.3* 142 4.1 110* 21*1 15
[**2151-10-8**] 07:05AM 89 31* 1.8*# 140 4.0 110* 20*1 14
[**2151-10-7**] 12:30PM 92 40* 2.9* 134 4.2 99 221 17
[**2151-10-6**] 01:01PM 107*
[**2151-10-6**] 01:01PM 29* 2.0* 134 4.3 99 21*1 18
.
proBNP
[**2151-10-12**] 05:00AM [**Numeric Identifier 94331**]*1
.
calTIBC VitB12 Folate Ferritn TRF
[**2151-10-12**] 05:00AM 192* 998* 8.6 188* 148*
PITUITARY TSH
[**2151-10-7**] 12:30PM 7.5*
THYROID T4 T3 Free T4
[**2151-10-9**] 01:28PM 67* 1.4
.
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calHCO3 Base XS
[**2151-10-9**] 01:18PM ART 101 26* 7.41 17* -5
.
MICRO:
[**2151-10-10**] 5:00 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2151-10-12**]**
GRAM STAIN (Final [**2151-10-10**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
AND IN CLUSTERS.
RESPIRATORY CULTURE (Final [**2151-10-12**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF FOUR COLONIAL MORPHOLOGIES.
.
STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2151-10-12**]**
OVA + PARASITES (Final [**2151-10-12**]):
NO OVA AND PARASITES SEEN.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
URINE Site: CATHETER
**FINAL REPORT [**2151-10-8**]**
URINE CULTURE (Final [**2151-10-8**]): NO GROWTH.
.
[**2151-10-7**] 12:30 pm BLOOD CULTURE NO SITE NOTED.
**FINAL REPORT [**2151-10-13**]**
AEROBIC BOTTLE (Final [**2151-10-13**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2151-10-13**]): NO GROWTH.
.
[**2151-10-6**] CXR, SINGLE VIEW:
IMPRESSION: Focal ill-defined opacity at the right lung base.
Although possibly due to focal atelectasis, an evolving
pneumonia in this location cannot be excluded. Dedicated PA and
lateral radiograph is recommended for better assessment.
.
[**2151-10-7**] CXR:
PA AND LATERAL CHEST: Comparison is made to study performed one
day earlier. Right atrial and biventricular pacing leads and ICD
devices remain in stable position. The patient has undergone
median sternotomy. Cardiac and mediastinal contours are
unchanged. The pulmonary vasculature is within normal limits.
Previously described ill-defined right basilar air space opacity
is not well seen on the current study and may have represented
atelectasis. There are no pleural effusions. Osseous structures
are unremarkable. There is apparent breakage of the most
inferior sternal wire.
IMPRESSION: No radiographic evidence of pneumonia on the current
exam.
.
[**2151-10-7**] KNEE XRAY:
RIGHT KNEE, TWO VIEWS.
Patient is status post three component knee prosthesis in
overall anatomic alignment. No hardware loosening,
periprosthetic lucency, or focal osteolysis is identified. There
is surrounding soft tissue edema and possible joint effusion.
Diffuse osteopenia. Scattered vascular calcification noted.
IMPRESSION: Status post right THR, without evidence of loosening
or fracture.
.
[**2151-10-7**] ECG:
Ventricular paced rhythm. Compared to the previous tracing of
[**2151-8-31**]
A-V pacing has been replaced by ventricular paced rhythm.
.
[**2151-10-9**] CXR:
IMPRESSION:
No significant change in the appearance of the chest since
[**2151-10-8**].
.
[**2151-10-11**] ECHO:
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. LV systolic function appears mildly
to moderately depressed with nearly global hypokinesis
particularly the inferolateral, anterior and basal inferoseptal
walls. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. Mild to moderate ([**12-20**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of [**2150-11-5**] overall left ventricular function
maybe similar but prior study is not available for direct
comparison.
.
[**2151-10-13**] PORTABLE CXR:
IMPRESSION: AP chest compared to [**10-9**] and 25:
Mild pulmonary edema has almost entirely cleared. Moderate right
pleural effusion persists. There are no focal pulmonary findings
to suggest pneumonia. Heart is normal size. Transvenous right
atrial pacer and right ventricular pacer defibrillator leads are
unchanged in standard placements continuous from the left
pectoral pacemaker. A remnant pacer wire can be traced as far as
the superior cavoatrial junction, but the tip is indistinct.
No pneumothorax.
Brief Hospital Course:
A/P: 80 y.o. woman, 4 weeks s/p R total knee replacement with
hypotension and abd pain and h/o diarrhea was transferred from
MICU to medicine in stable condition.
.
#Abdominal pain/vomiting/diarrhea - Likely patient received
perioperative antibiotics - ?C. diff, gastroenteritis. Patient
has elevated lactate, likely due to hypoperfusion, but will keep
possibility of mesenteric ischemia in mind. Pt's diarrhea
resolved and remained without diarrhea on medicine service. Pt's
vomiting also resolved. No C-diff per stool. Pt's abdominal pain
resolved, no possibility of mesenteric ischemia. Pt improved
clinically following administration of abx for presumed PNA.
.
#PNA-pt was initially treated with Azithromycin and Ceftriaxone
IV for increased temp, productive cough, decreased O2 sat, ?
consolidation vs fluid overload on CXR. Pt improved clinically
following abx course. On exam once transferred to medicine pt
had crackles [**12-21**] bases R>L and diminished breath sounds b/l. 2
episodes of O2 Sats decreased form 97%RA to 90%RA overnight. Pt
requiring 2-3L O2 to increase sats to 93-95%. CXR did not show
focal consolidation more c/w fluid and atalectatic picture. Pt's
sputum stian w/gram + cocci in pairs and clusters and growht
w/gram -rods. Pt was switched to levaquin PO to complete a 7 day
course.
Pt responded with Neb tx, improved cough w/guafenesin and on
emperic PNA treatment with improvement. Her O2 sats improved to
100% 1L NC.
Speech and swallow was consulted for ? Aspiration in setting of
desats at night. No overt aspiration noted with consult
evaluation, but could not rule out silent aspiration. Pt was put
on aspiration precautions and did not desat overnight
thereafter.
.
#Hypotension - Likely [**1-20**] severe volume depletion in the setting
of intermittent diarrhea and vomiting x 2 weeks and decreased PO
intake. Pt was hydrated with IVF. Her FeNa is 0.39, which
supported a pre-renal etiology. Pt's cardiac meds including
lasix were held while pt was rehydrated. Pt's BP were back up.
Throughout her admission on the medicine service her BP was up
to 180/100. She was given Toprol XL 25mg PO x1 per NF when
called o/n for elevated BP and an episode of desat to 90%RA. Pt
was restarted on Lisinopril 10mg and titrated up to her home
dose 20mg daily. Her home dose of Imdur was also added and
Toprol XL 50mg daily. Pt tolerated cardiac meds well. SBP 130s.
Pt was also put back on to her home dose of lasix 20mg PO daily.
.
#CAD - no current CP but pt has extensive cardiac hx inclusing
MI x 2 and CABG
Her CE were cycled and flat throughout her admission. She denied
any CP throughout her admission on medicine. She was continued
on her ASA 81mg daily.
.
#CHF - no peripheral edema and minimal evidence of fluid
overload on lung exam initially. Pt was aggressively hydrated to
maintain BP. Once transferred to medicine pt was noted to have
small b/l pleural effusions on CXR, which got a little worse. Pt
had mild 1+ pitting edema of LE b/l. On exam pt had diminished
breath sounds b/l R>L and had 2 episoded of decreased O2 sats
overnight. Pt was put on O2 to increased her O2 sats to 94-96%
on 3L. Pt was bolus'd IV lasix 40mg and 20mg as needed based on
clinical exam, O2 sats and fluid status. On [**2151-10-13**] pt was
given 20mg IV Lasix with good response put out ~2L. Her lung
exam improved. On last day of admission she had minimal, non
pitting edema of ankles, O2 sat 100% on 1 L. Her lisinopril was
increased to 20mg PO daily. Her BB has held initially for mild
CHF exacerbation and prior to d/c she was put back on her BB.
.
#HTN - patient had been hypotensive. Upon transfer to medicine
as noted above pt's cardiac meds held and pt became
hypertensive. Initially her lisinopril was restarted, and her
Imdur. Pt tolerated well with BP improvement from 180/100 to
140/70. She was also put back on her BB and lisinopril with good
BP and HR control.
.
#Hyperlipidemia
- Continued Lipitor
.
#GERD:
- Continued Protonix
.
#Anemia: worked up on previous admission - iron deficiency +
anemia of chronic disease. Her hct remained stable throughout
her admission from 28-30. She was hemodynamically stable
throughout her admission, no signs of bleeding.
.
#FEN:
- repleted lytes with goal K>4, Mg >2
- clear liquids, advance as tolerated
.
#Code: FULL
.
#Dispo: Pt was evaluated by physical and cleared to go back to
NH. Pt was in stable condition upon d/c.
Medications on Admission:
isosorbide
levothyroxine
lipitor
lovenox
lisinopril
prilosec
toprol XL
MoM
[**Name (NI) 94332**]
[**Name2 (NI) **]
Albuterol
Hydrocodone
acetaminophen
oxycodone
dulcolax
keflex
vicodin
Discharge Medications:
1. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours) for 4 weeks: please make sure her PCP is
aware before this is discontinued.
Disp:*qs * Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
8. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
1 days.
Disp:*1 Tablet(s)* Refills:*0*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Pneumonia and CHF exacerbation
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:2L
If you have these symptoms, call your M.D or go to the ED:
fevers, chills, cough, weakness, nausea, vomiting, diarrhea,
blood in stool or black stools
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2151-11-8**]
10:30
Provider: [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2151-11-24**] 10:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2152-1-5**]
10:00
Completed by:[**2151-10-14**]
|
[
"V43.65",
"V45.81",
"530.81",
"965.09",
"276.51",
"276.2",
"780.09",
"401.9",
"787.91",
"428.0",
"584.9",
"486",
"E850.2",
"272.4",
"280.9",
"414.8",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16300, 16371
|
10076, 14476
|
287, 293
|
16446, 16453
|
3169, 10053
|
16774, 17229
|
2825, 2829
|
14712, 16277
|
16392, 16425
|
14502, 14689
|
16477, 16751
|
2844, 3150
|
233, 249
|
321, 2619
|
2641, 2768
|
2784, 2809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,067
| 139,529
|
4922
|
Discharge summary
|
report
|
Admission Date: [**2122-2-28**] Discharge Date: [**2122-3-16**]
Service: MEDICINE
Allergies:
Iodine / Lipitor / Trazamine
Attending:[**First Name3 (LF) 20486**]
Chief Complaint:
Shortness of Breath
Renal Faillure
Major Surgical or Invasive Procedure:
HD catheter placement
History of Present Illness:
[**Age over 90 **] y/o F with recent complicated PMH including HTN, long
admission to [**Hospital1 2025**] and rehab for CVA (although not seen on
imaging) who presents today with acute worsening of SOB at home.
Per her daughter, she feels SOB every night but it usually
resolves on it's own. Last night, it just got worse and so she
came to the hospital.
In the ED, initial vital signs were 97.5, 66, 186/82, 24, 99% on
nasal canula. A room air sat was in the low 80s. Patient was
given vanco 1 gm, unasyn 3 gm, and clinda 600 mg. She was
started on a nitro gtt for hypertension. She was placed on bipap
and felt more comfortable. She also received zofran for nausea.
She receieved kayexcelate 30 mg PO x1 as well for K of 6.1.
On the floor, she in on the bipap mask at 50% FiO2 at 12/5,
tolerating it well. She is hypertensive with a SBP in the 160s.
She does not feel well and complains of feeling like she is not
getting enough air. She denies pain anywhere, specifically no
pain in her chest. She denies hx of nausea, vomiting, headache,
dizziness, fevers, chills, or cough at homee.
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:
1. Hypertension
2. Peripheral vascular disease
3. Hyperlipidemia
4. Urinary frequency/incontinence
5. Glaucoma
6. Tenosynovitis of wrists bilaterally
7. Colon Cancer status post resection 27 years ago, colonoscopy
in [**2113**] normal
8. Chronic renal insufficiency, baseline creatinine 1.2-1.4,
hyperkalemia baseline ~5.4
9. Small bowel obstruction status post resection of gangrenous
bowel
10. Pseudogout
11. S/P Cholecystectomy.
12. Bladder resuspension
13. Detached retina
14. Bilateral knee OA
Social History:
She has a 40 pack-year smoking history, quit 30 years ago. She
ambulates with a walker. She has home health aid who visits her
5 times per week. Her daughters [**Name (NI) **] and [**Name (NI) 8214**] live in the same
complex and offer assistance. The patient lives on the [**Location (un) 17879**] of house with several flights of stairs for access.
Family History:
No history of colon cancer or breast cancer. One of her sons
recently passed away.
Physical Exam:
Dishcarge PE:
Vitals - T: 96.0 BP:147/73 (140/60-147/73) HR:62 (62-64) RR:18
02 sat: 100% on 2L (drops sats while sleeping, likely OSA)
.
GENERAL: Pleasant, well appearing elderly female in NAD, without
perseveration or echolalia, A+Ox3 (NOTE she is intermittently
somnolent after HD)
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils small, minimally reactive. MMM. OP
clear. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops.
LUNGS: CTAB, Greatly improved air movement biaterally on
posterior exam. clean tunneled line in place.
ABDOMEN: ostomy in place with brown solid stool. NABS. Soft,
NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: Thin skin with multiple ecchymotic lesions on UE and
right axilla, right medial distal forearm PPD placed.
Pertinent Results:
LABS ON ADMISSION:
[**2122-2-28**] 09:45AM BLOOD WBC-5.9 RBC-3.48* Hgb-9.8* Hct-31.0*
MCV-89 MCH-28.2 MCHC-31.6 RDW-15.8* Plt Ct-271
[**2122-2-28**] 09:45AM BLOOD Neuts-79.0* Lymphs-14.8* Monos-5.2
Eos-0.6 Baso-0.5
[**2122-2-28**] 09:45AM BLOOD Plt Ct-271
[**2122-2-28**] 09:57PM BLOOD Ret Aut-3.3*
[**2122-2-28**] 03:17PM BLOOD
[**2122-2-28**] 09:45AM BLOOD Glucose-115* UreaN-77* Creat-3.3* Na-141
K-6.1* Cl-105 HCO3-23 AnGap-19
[**2122-2-28**] 09:45AM BLOOD CK(CPK)-45
[**2122-2-28**] 09:45AM BLOOD CK-MB-NotDone
[**2122-2-28**] 09:45AM BLOOD cTropnT-0.08*
[**2122-2-28**] 03:17PM BLOOD Calcium-8.9 Phos-5.2* Mg-1.9
[**2122-2-28**] 09:57PM BLOOD Hapto-99
[**2122-3-1**] 06:44AM BLOOD Vanco-10.3
[**2122-2-28**] 10:03AM BLOOD Lactate-0.9
LABS ON TRANSFER FROM ICU:
[**2122-3-6**] 02:04AM BLOOD WBC-6.3 RBC-2.75* Hgb-8.1* Hct-25.4*
MCV-92 MCH-29.5 MCHC-32.0 RDW-15.3 Plt Ct-178
[**2122-3-6**] 02:04AM BLOOD Plt Ct-178
[**2122-3-6**] 02:04AM BLOOD
[**2122-3-6**] 02:04AM BLOOD Glucose-108* UreaN-61* Creat-3.7* Na-139
K-5.7* Cl-109* HCO3-22 AnGap-14
[**2122-3-6**] 02:04AM BLOOD Calcium-7.7* Phos-7.0* Mg-2.2
[**2122-3-6**] 05:50AM BLOOD Vanco-22.0*
URINE CHEMISTRIES:
[**2122-3-5**] 09:47AM URINE Hours-RANDOM UreaN-378 Creat-75 Na-38
K-29
[**2122-3-2**] 11:00AM URINE Hours-RANDOM UreaN-521 Creat-82 Na-42
[**2122-3-5**] 09:47AM URINE Osmolal-317
[**2122-3-2**] 11:00AM URINE Osmolal-357
EKG [**2122-2-28**]:
Sinus rhythm with atrial premature beats. Prolonged P-R
interval. Poor R wave progression. Consider prior anteroseptal
myocardial infarction versus normal variant. Compared to the
previous tracing of [**2121-5-19**] the findings aresimilar.
CHEST X-RAYS:
[**2-28**]:
1. Congestive heart failure.
2. Bibasilar effusions/atelectasis and consolidations.
[**3-1**]:
As compared to the previous radiograph, the extent of the
pre-existing right pleural effusion has decreased. A small
pleural effusion on the left is still present. Unchanged massive
cardiomegaly, unchanged signs of overhydration. Given that
additional pneumonia cannot be excluded because of the existing
areas of atelectasis, short-term followup after dehydration is
recommended.
[**3-3**]:
Increasing moderate bilateral pleural effusion, right greater
than left and persistent severe cardiomegaly point to cardiac
decompensation and/or volume overload. Coexistent pneumonia
would be obscured.
[**3-5**]:
In comparison with the study of [**3-4**], there has been substantial
change in the degree of obliquity of the patient. Central line
remains in place. Extensive bilateral pleural effusions persist,
apparently worse on the right with underlying areas of
compressive atelectasis. No evidence of acute focal pneumonia.
ECHO [**3-2**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-13**]+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
[**Age over 90 **]F with PMH of HTN, hyperlipidemia, recent possible CVA, and
chronic kidney disease presents with worsening SOB starting last
night and continuing until morning. CXR with evidence of
pneumonia and effusion. Also with worsening renal failure and
hyperkalemia.
# Hypoxic Respiratory Distress: new worsening hypoxic
respiratory failure with recent history of nighttime SOB that
seems to be chronic. PNA vs Orthopnea [**1-13**] worsening CHF, but
with CXR concerning for RLL pneumonia. No significant
leukocytosis, no fever or chills. No h/o CAD or CHF. Treated for
HAP with vanc and cefepime, with cipro added later for double
gram negative coverage. Patient's Oxygen saturations improved
but her Oxygen requirement never reached 0. My highest
suspicion is that she has obstructive sleep apnea.
Plan going forward:
-Please keep continuous Oxygen at night (2 liters should be
fine)
-Patient would benefit from polysomnography
# Acute on Chronic Renal Failure with Oliguria1: Previous
baseline ~2.0 with recent levels more in 2.5 to 3.0 range,
elevated to 3.4 on admission. Possibly new baseline vs acute
pre-renal etiology. FENa 1.2% (equivocal). Gently improved with
fluids, then worsened with diuresis, however overall failed to
improve to baseline. Urine output remained low averaging 15-20cc
per hour. Restarted PO bicarb for ongoing chronic renal acidosis
and sevelamer for hyperphosphatemia. Also increasing phosphate
and difficulty managing potassium. Began HD on [**3-6**]. Her bicarb
was stopped.
.
Plan going forward:
- The family's understanding is that this is a "trial" of
dialysis and that she may come off of dialysis if she doesn't
like or her renal function returns in a month or two. Dr. [**Last Name (STitle) **]
is well aware of the situation.
- PLEASE KEEP AN EYE ON HER BICARB, IN PATIENTS WITH OSA,
ACIDEMIA CAN BE THE DRIVE TO BREATHE AT NIGHT, AND MAKING HER
TOO ALKALEMIC WILL HINDER THIS. DISCUSS RUNNING HER TO A LOWER
BICARB WITH DR. [**Last Name (STitle) **].
# HTN: Unclear baseline BP but last progress note says BP
130/70. Hypertensive on admission, possibly contributing to
edema leading to worsening SOB. Started on nitro gtt in the ED,
weaned off overnight. On atenolol and amlodipine at home for BP
control. Held amlodipine to increase renal perfusion without
significant increase in urine output. Patient was discharged on
only metoprolol with good effect.
# Hyperphospatemia: [**1-13**] ARF. Restarted sevelamer. Low
phosphorous diet. Started hemodialysis. I would be aware of how
her phosphorous is, as she has been on the low side and we
briefly considered stopping sevalemer.
# Hyperkalemia: K+ 6.1 on admission in setting of acute on
chronic renal failure. Decreased with kayexelate however
remained difficult to control until initiation of HD.
# Mental status: remained lucid and almost consistently fully
oriented, however was felt to be somewhat confused during her
last two nights in the ICU. Of note she had received 25mg
trazadone the night prior, and this was added to her adverse
reaction list. Briefly endorsed hallucinations of kids walking
around her room during last day of ICU stay, felt likely minor
ICU-induced psychosis. This completely resolved on the floor.
# Pulmonary Hypertension: seen on echo [**3-2**]. No history of COPD
or other documented lung disease. Consider outpatient
pulmonology follow up if felt appropriate.
-outpatient repeat echo after PNA if clinically indicated.
Medications on Admission:
Levothyroxine Sodium 50 mcg PO/NG DAILY
Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain on hand 12 hours on
12 hours off
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
Aspirin 81 mg PO/NG DAILY
Ondansetron 4 mg IV Q8H:PRN nausea
Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
OxycoDONE 2.5-5 mg PO/NG Q6H:PRN pain
CefePIME 500 mg IV Q24H
Ciprofloxacin HCl 500 mg PO/NG please give after every HD
session Sodium Bicarbonate 650 mg PO/NG [**Hospital1 **]
Docusate Sodium 100 mg PO BID:PRN constipation
Heparin 5000 UNIT SC TID
Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic every
twelve (12) hours.
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP<100, HR<60.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain on hand: apply for 12 hours on/ remove for 12
hours.
9. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: [**12-13**] puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing: patient may refuse.
11. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID PRN () as needed for pain.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
primary:
Pneumonia
Pleural effusion
Acute on chronic Renal Failure
delirium
Secondary:
HTN
CVA/ TIA
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for shortness of breath. You were
found to have a pneumonia and increase fluid in your lungs. This
was thought to be due to worsening kidney function. Your Kidneys
were not working well and you were started on hemodialyses. You
also had a hemodialyses catheter placed on the right side of
your neck. For your pneumonia you were treated with strong
antibiotics and you had improvement of your symtpoms. You were
initially staying at the ICU and you were then transferred to a
regular medical unit.
We have made the following medication to your current
management:
-
Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2122-4-16**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3940**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2122-8-18**] at 1 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2122-4-21**] at 1 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 20487**]
Completed by:[**2122-3-16**]
|
[
"272.4",
"416.0",
"584.9",
"496",
"518.81",
"511.9",
"482.9",
"244.9",
"585.6",
"403.91",
"V10.05",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
13035, 13101
|
7442, 10260
|
272, 296
|
13246, 13246
|
3815, 3820
|
14064, 15091
|
2789, 2873
|
11681, 13012
|
13122, 13225
|
10944, 11658
|
13428, 14041
|
2888, 3796
|
1435, 1882
|
198, 234
|
324, 1416
|
3834, 7419
|
13261, 13404
|
1904, 2404
|
2420, 2773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,554
| 121,052
|
28761
|
Discharge summary
|
report
|
Admission Date: [**2148-3-21**] Discharge Date: [**2148-3-25**]
Date of Birth: [**2096-6-5**] Sex: M
Service: MEDICINE
Allergies:
Cold Medicine
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
BRBPR and Hypotension
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
This is a 51 yo man with a history of Hep C Cirrhosis c/b HCC in
[**2145**], diastolic dyfunction with EF 65% who presents with c/o
melena. Apparently the patient was admitted last week for a
colonoscopy. The patient had a colonoscopy on [**2148-3-15**] which
revealed polyps in the transvere colon, sigmoid colon, ascending
colon, and the hepatic flexure which all underwent biopsy. Post
biopsy he had a fever and was diagnosed with RLL PNA on [**2148-3-16**].
He was discharged home on a 7 day course of levofloxacin. Since
discharge, the patient noted purple streaks of blood in his
stool starting this AM, and has had 3 BM today. He denies
associated emesis, CP, palpitations, or abdominal pain. He does
admit to some orthostasis and dizziness earlier today.
.
In the ED, the pts vitals were: T 97.9 HR 65 BP 96/51, RR 16,
Sat 99%RA. He received 3 L NS in the setting of his SBP dropping
to 86. He was guaiac positive. NGL was negative for UGI bleed.
Hepatology saw the pt with plan for colonoscopy in the AM.
Past Medical History:
Hep C Cirrhosis diagnosed [**2145**] c/b HCC
1 episode of afib several years ago, coumadin d/c'd
Diastolic Dysfunction EF 65% in [**11-28**]
Moderate AS
Diet Controlled DM
H/o ETOH abuse
GI Polyps
Social History:
Lifelong smoker--35 pack yrs, quit several wks ago. H/o ETOH
abuse but quit. H/o marijuana abuse and IV drug abuse but quit.
An environmental worker. He has no children. He is single and
lives in [**Location 38**].
Family History:
The patient's mother had breast cancer but is doing well and is
alive. No other GI cancers. No history of hep B or hep C in the
family.
Physical Exam:
Vitals: afebrile BP 116/55 HR 60 RR 24 Sat 100% RA
Gen: middle-aged man, NAD, sitting up in bed
HEENT: PERRL, conjunctivae mildly icteric, MMM
Neck: supple, no LAD, JVD not appreciated
CV: RRR, grade 4/6 SEM at LUSB radiating to carotids
Lungs: CTAB
Ab: soft, NTND, NABS, no HSM by percussion
Extrem: no c/c/e, full dp/pt pulses
Neuro: no asterixis, A and O x3, CN II-XII grossly intact
Guaiac positive in ED
Pertinent Results:
Admission Labs
[**2148-3-21**] 05:28PM BLOOD WBC-7.0 RBC-2.89* Hgb-10.5* Hct-29.8*
MCV-103* MCH-36.2* MCHC-35.1* RDW-14.5 Plt Ct-81* Neuts-81.9*
Lymphs-9.3* Monos-7.1 Eos-1.7 Baso-0
[**2148-3-21**] 05:28PM BLOOD PT-16.0* PTT-30.0 INR(PT)-1.5*
[**2148-3-21**] 05:28PM BLOOD Glucose-214* UreaN-15 Creat-1.1 Na-131*
K-4.3 Cl-98 HCO3-26 AnGap-11 Calcium-8.2* Phos-2.3* Mg-1.6
Ammonia-63* Digoxin-0.7*
ECHO [**3-25**] [**2147**]
Conclusions:
The left atrium is markedly dilated. The right atrium is
moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. There is
mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is
normal. Regional left ventricular wall motion is normal. There
is no
ventricular septal defect. Right ventricular chamber size and
free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets
are severely thickened/deformed. There is moderate aortic valve
stenosis (area
0.8-1.19cm2). No aortic regurgitation is seen. The mitral valve
leaflets are
mildly thickened. No mass or vegetation is seen on the mitral
valve. Trivial
mitral regurgitation is seen. [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 prior study (images reviewed) of [**2147-12-7**],
there is now
moderate to severe aortic stenosis.
IMPRESSION: No valvular vegetations seen. If clinically
indicated, a TEE may
be better to exclude a small valve vegetation.
Brief Hospital Course:
GIB: The patient was initially in the MICU, where he was
stable and quickly transferred to the floor. The patient's
course was stable. His initial Hct was 29.8 within his baseline,
with his repeat Hct being 28.4. His INR was 1.5. He received 1U
of FFP, 1u of platelets and vitamin K 10SC.
The patient remained HD stable. Colonoscopy was performed and
the area of prior polypectomy was embolized, cauterized
successfully. The patient was transferred to [**Hospital Ward Name 121**] 10 for further
mgmt. The patient continued to have persistently guaiac
positive stools, however his Hct remained stable on the floor.
He had no further episodes of blood loss or melena and was
scheduled for an EGD as an outpatient.
.
# FEVER: The patient spiked a fever on the floor which quickly
resolved. He has moderate AS and was not given abx prior to
scope on [**3-15**]. Post-procedure, spiked to 103 and had rigors.
Cultures were negative and patient was felt to have a pneumonia,
so was diagnosed w/ 7d course of levofloxacin (last dose 3/31).
Was not given any other abx before scope. ? if patient could
have had a transient bacteremia peri- or post-procedure, so an
echocardiogram was obtained which showed no vegetations.
Numerous blood cultures also showed no growth.
.
# CIRRHOSIS/COAGULOPATHY: No evidence of encephalopathy. Lasix
was held. The patient had EGD in [**1-31**] which showed 3 cords of
grade II-III esophageal varices. He is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] was
given blood products/vitamin K prior to scope.
.
# HYPOTENSION: Likely related to GI bleed. Resolved and the
patient was slowly re-started on his blood pressure medications.
.
# h/o AFIB: NSR currently. Digoxin was continued. Diltiazem was
initially held but then restarted. No anticoagulation given
liver dysfunction.
.
# DM: FS QID + ISS.
.
# HYPONATREMIA: Resolved. It was previously likely in setting of
cirrhosis.
.
# FEN: Advance diet to regular. No further IVF. Checked lytes
daily, repleted prn.
.
# ACCESS: 2 LBIV
.
# PPX: Pneumoboots, PPI, no bowel regimen currently
.
# FULL CODE
.
# COMM: with patient; father is [**Name (NI) **] [**Name (NI) **] #[**Telephone/Fax (1) 69508**] .
..
Medications on Admission:
Coreg 3.125 mg b.i.d.
diltiazem XR 120 mg daily
digoxin 0.25 mg daily
Lasix 40 mg every day
Aldactone 100 mg every day
lisinopril 10 mg daily
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
5. 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*
6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Bleeding from polypectomy site
Aortic stenosis
.
Secondary diagnosis:
Hepatitis C
Cirrhosis
HCC
Atrial fibrillation
DM - diet controlled
Discharge Condition:
Good. Afebrile, BP and HR stable.
Discharge Instructions:
You were admitted for evaluation of bleeding from your rectum.
Repeat colonoscopy was performed and it found that you were
bleeding from the site of your polypectomy. The bleeding was
controlled with injections and cautery. Your hematocrit remained
stable throughout your admission, but you were given blood
products to lower your bleeding risk peri-procedure.
Post-colonoscopy, you developed a fever and were started on
antibiotics in case of infection, particulary on your aortic
valve. You remained afebrile for the rest of your
hospitalization and all cultures showed no growth at time of
discharge. You had an ECHO performed which showed a worsening of
your heart murmur, but no infection on your valve. You were
discharged on cefpodoxime for a 7 day course and you should
follow-up with your outpatient cardiologist within the next 4
weeks.
.
You should have a CXR performed in [**3-29**] weeks to evaluate for
resolution of your pneumonia. Please set this up through your
PCP's office.
.
Please take all medications as prescribed. Several changes have
been made:
1) Your LASIX and ALDACTONE are being held until you follow up
with Dr. [**Last Name (STitle) 497**] on [**2148-3-27**].
2) Your LISINOPRIL has been restarted upon discharge.
3) You are being discharged with a course of CEFPODOXIME -
please take all of these antibiotics as prescribed.
.
Please keep all your follow up appointments as outlined below.
.
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, shortness of breath,
difficulty breathing, chest pain, lightheadedness or dizziness,
dark or tarry stools, bright red blood from your rectum, or any
other worrisome symptoms.
Followup Instructions:
Please keep the following appointments:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-3-27**] 1:40
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2148-6-5**] 10:00
.
Please make an appointment with your PCP [**Last Name (NamePattern4) **] [**3-29**] weeks so that
you can have a repeat CXR performed to evaluate for resolution
of your pneumonia.
.
Please also make an appointment with your outpatient
cardiologist within the next 4 weeks. Please make this
appointment at your convenience.
|
[
"V10.07",
"572.3",
"458.9",
"276.1",
"V15.82",
"E878.8",
"569.84",
"E849.7",
"070.70",
"424.1",
"571.2",
"562.10",
"998.89",
"780.6",
"V12.72",
"998.11",
"250.00",
"456.21",
"V45.89",
"427.89",
"427.31",
"305.03",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.07",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
7196, 7202
|
4064, 6293
|
294, 307
|
7402, 7438
|
2402, 4040
|
9190, 9737
|
1820, 1957
|
6486, 7173
|
7223, 7223
|
6319, 6463
|
7462, 9167
|
1972, 2383
|
233, 256
|
335, 1351
|
7312, 7381
|
7242, 7291
|
1373, 1572
|
1588, 1804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,873
| 186,838
|
22898
|
Discharge summary
|
report
|
Admission Date: [**2192-12-24**] Discharge Date: [**2193-2-20**]
Date of Birth: [**2134-9-4**] Sex: M
Service: SURGERY
Allergies:
Sulfur, Elemental / Iodine / Hyzaar
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
end stage liver disease (NASH)
ischemic colitis
Major Surgical or Invasive Procedure:
exploratory laparotomy [**12-25**]
hartmann procedure - subtotal colectomy & [**Doctor Last Name **] ileostomy
[**1-21**]: revision of ileostomy
VAC placement
multiple swan ganz catheter placements
arterial line placement
dobhoff placement
endotracheal intubation
placement of HD catheter
History of Present Illness:
Unfortunate 58M with ESLD from NASH & subsequent portal vein
thrombosis, who developed sharp abdominal pain, with guaiac+
stools. On presentation, he was hypotensive & encephalopathic.
Endoscopy was unremarkable but sigmoidoscopy showed evidence of
ischemic colitis in the descending colon.
Past Medical History:
nonalcoholic steatohepatitis
grade II cirrhosis (diagnostic biopsy [**2189**])
h/o encephalopathy & ascites
obesity
sleep apnea
DM2, diet controlled
anasarca
pulmonary hypertension
Social History:
no etoh
no cigs
no IVDU
Family History:
father +CAD
mother +fatty liver
Physical Exam:
T:97 P:53 R:20-30 BP:89/46 SaO2:100% RA
General: Awake, moaning, encephalopathic, obese and jaundice.
HEENT: NC/AT, PERRLA, 4mm B, EOMI without nystagmus, + icterus,
MMM, no lesions/petechiea noted in OP
Neck: Obese, supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Bradycardic, nl. S1S2, no M/R/G noted. Distant Heart
Sounds
Abdomen: Obese, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. No
Extremities: Brawny edema B, with 4 + Pitting edema. + Sacral
edema, anasarca.
Skin: no rashes or lesions noted. no eccyhmosis
Neurologic: moving all extrems, not alert/oriented
Pertinent Results:
Please refer to careweb for specific laboratory data.
Brief Hospital Course:
[**12-24**]: Admitted to MICU service. GI & transplant surgery teams
consulted.
[**12-25**]: Colonoscopy showed ischemic colitis. Taken to OR for
emergent ex lap, where a subtotal colectomy & end ileostomy was
performed. Pathology eventually revealed mucosal infarction of
the colon & transmural necrosis of the small bowel.
[**12-25**]: Admitted to SICU for postop care. Although his mental
status & hemodynamic profile improved folliwng his colectomy,
this was significant for several blood product transfusions for
blood loss anemia & thrombocytopenia.
[**1-2**]: He was transferred to [**Hospital Ward Name **] 10 in good condition, where he
was followed by renal & ID consultants. His postop course was
complicated by large ostomy outputs. Eventually it was realized
that Mr [**Known lastname **] had developed an ascitic leak adjacent to his
ostomy.
[**1-21**]: Return to OR for repair of his ascitic leak & placement of
2 [**Doctor Last Name **] drains. Returned to SICU for postoperative management.
This 2nd prolonged ICU stay can be summarized in an organ system
approach:
NEURO: His mental status gradually cleared, and his pain was
covered with intermittent opiates. He was continued on
rifamixin to prevent encephalopathy.
CV: His cardiac function was following with echocardiograms & PA
catheters. He remained in a high output cardiac failure c/w his
hepatorenal syndrome, which was treated intermittently with
midodrine/octreotide & levophed.
RESP: Postop, he did well with respect to his repiratory status.
However, he developed worsening repiratory failure requiring
intubation on [**2-10**]. Post-intubation CXR revealed CHF vs. ARDS,
which was treated with diuresis.
FEN: Mr [**Known lastname 59177**] poor liver function led to worsening renal
failure, and eventually he became anuric with a rising
creatinine. A R IJV dialysis line was placed on [**2-11**] & he was
maintained on continuous [**Last Name (un) **]-venous hemodialysis.
GI: His GI tract worked well, and he was tolerated tube feeding
via a postpyloric dobhoff tube. His liver function never
completely improved, however, and developed an peritoneal leak
from midline wound because of his persistent ascites. On [**2-8**],
he was noted to have blood loss anemia & melenic stools. An
endoscopy showed gastric varices & other evidence of portal
gastropathy.
HEME: Because of his liver failure, Mr [**Known lastname **] had trouble with
blood loss & renail failure anemia, thrombocytopenia, & elevated
INR. He required multiple transfusions of RBC, platelets & FFP
to prevent excessive bleeding.
ID: This ICU stay was notable for recurrent infections, with
[**Female First Name (un) **] repeatedly growing from his foley catheter & his [**Doctor Last Name **]
drains. He developed a 2nd ascitic leak, this time from his
midline incision, which was treated with a VAC device & the
[**First Name9 (NamePattern2) 59178**] [**Doctor Last Name **] drains. He was covered with broad spectrum
antibiotics & amphotericin bladder irrigation, but was unable to
clear the fungus in his peritoneal fluid.
ENDO: Following his surgery, Mr. [**Known lastname **] developed marked
insulin resistance & required an insulin drip. He was
transitioned to large twice daily NPH doses and a sliding scale
of regular insulin.
DISPO: After he was declined for orthotopic liver
transplantation, a family meeting was held on [**2-20**]. He was made
CMO, his pressors were discontinued & a morphine drip was
instituted. He expired comfortably at 5:17pm with his family
present. An autopsy was requested by his wife [**Name (NI) **].
Medications on Admission:
Lactulose 20gm TID
Protonix 40mg po qd
Hep 5000QS Daily
Hydrocortisone 100mg po TID
Simethicone 80mg po q12 prn
ZOSYN 2.25 IV q8 ([**12-24**] 2:00pm last dose)
Midodrine 10mg po TID
Anzemet 12.5mg IV prn
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
NASH
cirrhosis
portal gastropathy
h/o hepatic encephalopathy
PV thrombosis
CRI
ARF requiring CVVHD
OSA
pulm HTN
obesity
DM, poorly controlled
anasarca
s/p appy
ischemic colitis
hepatorenal syndrome
bacterial peritonitis
funguria
hyponatremia
portal hypertension
sepsis
septic shock
ascitic leak
CHF
ARDS
high output cardiac failure
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2193-2-20**]
|
[
"569.69",
"571.8",
"785.52",
"327.23",
"456.8",
"578.1",
"278.01",
"570",
"572.3",
"401.9",
"285.1",
"112.3",
"584.5",
"286.7",
"557.0",
"452",
"567.21",
"428.0",
"038.9",
"518.81",
"287.5",
"112.5",
"995.92",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"99.04",
"38.93",
"38.91",
"45.73",
"96.04",
"46.41",
"00.14",
"45.62",
"45.75",
"96.72",
"99.07",
"45.13",
"46.23",
"99.05",
"38.95",
"96.6",
"99.15",
"89.64",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5868, 5877
|
1964, 5585
|
342, 633
|
6253, 6264
|
1886, 1941
|
6316, 6478
|
1215, 1248
|
5840, 5845
|
5898, 6232
|
5611, 5817
|
6288, 6293
|
1263, 1867
|
255, 304
|
661, 954
|
976, 1158
|
1174, 1199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,744
| 139,356
|
7480
|
Discharge summary
|
report
|
Admission Date: [**2188-12-23**] Discharge Date: [**2188-12-30**]
Date of Birth: [**2143-2-9**] Sex: M
Service: TRANS.[**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 45-year-old male who
was presenting for a pancreas transplant. The patient's past
medical history included end-stage renal disease status post
kidney transplant in [**2187-1-4**].
mellitus, hypertension, right ankle Charcot disease and
multiple lacunar infarcts and heart murmur noted since
childhood.
ALLERGIES: Cipro with nausea.
MEDICATIONS AT HOME: Include ________ 100 b.i.d., prednisone
day, Zantac 150 mg b.i.d., aspirin 81 mg q. day, Lopressor
125 mg b.i.d., lisinopril 20 mg q. day, Os-Cal 1000 mg
t.i.d., Fosamax 70 mg q. week, NPH 50 in the a.m. and 50 in
the p.m. and sliding scale insulin.
SOCIAL HISTORY: The patient does not smoke and does not
drink alcohol.
RADIOLOGY: Preoperative x-ray was normal.
ELECTROCARDIOGRAM: Preoperative EKG was normal sinus rhythm.
PHYSICAL EXAMINATION: Patient presented afebrile. Vital
signs were stable.
HOSPITAL COURSE: The patient tolerated the procedure well.
On postoperative day one patient continued to be afebrile.
Vital signs were stable. The patient was started on
Solu-Medrol taper, immunoglobulin. On postoperative day two
patient continues to be afebrile with vital signs stable.
His urine out, amylase and lipase were both decreasing. All
other electrolytes were within normal limits. Blood sugars
were within desired range. On day three patient continued
NPO, intravenous fluids, good urine output. Amylase and
lipase continued to decrease. Electrolytes otherwise
continued to be within normal limits. White count was noted
to be decreased and, therefore, immunoglobulin was held.
Other medication was continued. On postoperative day four
patient continued to be afebrile. Amylase and lipase
continued to decrease and other electrolytes were within
normal limits. The patient's white count was noted to be
increasing and, therefore, patient received immunoglobulin
dose, begun on CellCept and given Solu-Medrol and FK506 and
FK. On postoperative day five, patient's amylase and lipase
continued to decrease as desired and electrolytes were within
normal limits. Patient was continued on Solu-Medrol,
CellCept and FK506. Due to the levels was decreased to 1 mg
b.i.d. and patient was started on sips. NG tube was
discontinued and Foley catheter was discontinued as well. On
postoperative day five patient was improved. Enzyme levels
continued to decrease. Patient was started on clears.
Patient was Hep-Lok'd. Continued immunosuppression, CellCept
and Solu-Medrol taper and FK506. On postoperative day six
patient had advanced to regular diet and continued to
improve. Patient continued immunosuppression which included
CellCept, prednisone and FK506. Patient was felt to be doing
well enough to be ready for discharge on the [**1-30**].
DISCHARGE INSTRUCTIONS: Patient to be going home with all
the special medications arranged per the Transplant Center.
The patient will be following up with Dr. [**Last Name (STitle) **] and the
Transplant Center Division at [**Hospital1 188**] on appointments arranged through the office. The
patient will be going home with Percocet for pain
medications.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Status post cadaveric pancreas transplant.
2. Hypertension.
3. Right ankle Charcot's disease.
4. Multiple lacunar infarcts.
5. Insulin-dependent diabetes mellitus.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2188-12-29**] 13:22
T: [**2188-12-29**] 13:40
JOB#: [**Job Number **]
|
[
"V42.0",
"713.5",
"250.41",
"369.4",
"V12.59",
"577.8",
"401.9",
"250.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.82"
] |
icd9pcs
|
[
[
[]
]
] |
3385, 3808
|
1091, 2944
|
2969, 3313
|
564, 815
|
1018, 1073
|
3328, 3364
|
195, 542
|
832, 995
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,742
| 191,527
|
6161
|
Discharge summary
|
report
|
Admission Date: [**2175-11-30**] Discharge Date: [**2175-12-9**]
Date of Birth: [**2113-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
1) Urgent coronary artery bypass graft x4 with left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to posterior descending artery, obtuse marginal and
diagonal arteries.
2) Emergency ECMO and cardiopulmonary bypass for cardiac arrest.
History of Present Illness:
Patient is a 62 y/o male with a PMH significant for CAD s/p
prior cath and recommendation for CABG in [**2163**] at [**Hospital1 2025**], who
reported to PCPs office with exertional dyspnea and productive
cough. EKG at the PCP's office showed ? ST
depressions in V6 and patient was sent to the ER for evaluation.
Ruled in for myocardial infarction. Cath done [**2175-12-1**] showed
LM:diffuse 30-40%
LAD:heavily calcified; ectatic sausage-shaped proximal vessel
with distal relative 60%; prox-mid 70% at S1 then 70% leading to
80% at S2; distal LAD 70%; major D1 with tortuous distal hairpin
turn (diseased to 60%) and prox diffuse 80%; modest caliber D2
with origin 80%; some septal collaterals to RPDA
LCx:heavily calcified; prox 60% after high atrial branch;
prox-mid 60%; major OM tubular 50%; distal AV groove Cx to RCA
RCA:moderately calcified; diffusely diseased prox RCA with
serial mid vessel occlusions with very faint filling of the mid
RCA. The patient was referred for CABG.
Past Medical History:
Cardiac Risk Factors:(+)Diabetes,(+)Dyslipidemia,(+)Hypertension
Cardiac History:
Percutaneous coronary intervention, in [**2163**] at [**Hospital1 2025**], reported to
have 90% prox LAD after large diagonal, feeding primarily the
septum, RCA has tight mid stenosis after bend (?difficult to
approach percutaneously).
Other Past History:
OSA
Peripheral Neuropathy
Erectile Dysfunction
Adenoma Colonic Polyps
Social History:
Etoh-very little
Tobacco-Remote
Illicits-denies, says he previously smoked a lot of MJ
He lives with his second wife only. [**Name2 (NI) **] a son age 22. Had a
ladder accident in [**2152**], has been disabled,selling used cars and
living off inheritance. Education was [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Location (un) **]
where he studied elementary education.
Family History:
Father died at age 51 of heart disease. Mother lived into her
80's and had CABG at age 78.
Physical Exam:
T: 98.2??????F HR, 108 bpm, BP 108/61, RR: 35 SpO2: 96%
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale, No(t) Sclera
edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : from anterior, No(t) Crackles : , No(t) Wheezes : ,
No(t) Rhonchorous: ), Anteriorly
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, situation,
Movement: Purposeful, Tone: Normal
Pertinent Results:
CXR (Portable) [**2175-11-30**]: Mild cardiomegaly is exaggerated by
lordotic positioning. There may be very mild pulmonary edema.
Conventional radiograph should be obtained for confirmation.
Atelectasis at the left lung base is mild. Pleural effusion is
small if any. No pneumothorax.
.
Cardiac catheterization [**2175-12-1**]:
1. Three vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
3. Moderate primary pulmonary hypertension.
.
Echocardiogram: The left atrium is moderately dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
hypokinesis of the distal half of the anterior septum, anterior,
lateral wall, and apex. There is mild hypokinesis of the
remaining segments (LVEF = 35 %). No masses or thrombi are seen
in the left ventricle. Right ventricular chamber size and free
wall motion are normal. The ascending aorta and aortic arch are
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate ([**11-25**]) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size with regional
dysfunction c/w multivessel CAD. Moderate pulmonary artery
systolic hypertension. Mild-moderate mitral regurgitation.
Dilated thoracic aorta.
.
Carotid Duplex:
1. Less than 40% stenosis of the right internal carotid artery.
2. 80-99% stenosis of the left internal carotid artery.
Brief Hospital Course:
62 year old male with PMH significant for CAD, HL, DM and HTN
who presented with 7-10 days of shortness of breath, found to
have had an anterior MI. Prior to be taken to the operating room
the patient underwent cardiac catheterization which showed that
he had three vessel disease and severe diastolic dysfunction.
Initially after his catheterization he was diuresed in the CCU
with a swan ganz catheter in place, carotid ultrasounds which
showed an 80-99% stenosis of his left ICA.
He was taken to the operating room for a coronary artery bypass
graft surgery on [**2175-12-6**]. See operative note for details. He
was transferred to the CVICU in stable condition. He was weaned
off epinephrine on post operative day 1 and neosynephrine was
weaned post operative day 2 with good hemodynamics (cardiac
index >2). He was extubated post operative night without
incidence. Chest tubes and pacing wires were removed per
caridac surgery protocol. He was noted to have a small left
apical pneumothorax on the post chest tube CXR, which remained
stable and he maintained good oxygen saturation. He was
transferred to the floor on post operative day 2 in stable
condition.
Postoperatively on day #2 in the evening after a visit to the
bathroom, he was sitting in a chair and underwent sudden
ventricular fibrillation and was initially
defibrillated successfully with 300 Joules. He was intubated on
the step down unit and transferred to the CVICU. Recurrent
attacks of ventricular fibrillation occurred after he was
transferred to the unit. Subsequent resuscitation was continued
in the ICU. He was put on ECMO after multiple internal cardiac
massage after opening the chest in the intensive care unit
failed. Subsequently he was
taken to the operating room in ventricular fibrillation on ECMO
for conversion to cardiopulmonary pass and for arresting the
heart to see if recovery happens. There the ECMO subcu was
converted to a full cardiopulmonary bypass. A left ventricular
vent was also inserted along with pulmonary artery vent for
complete decompression of the heart. After 1 hour of arrest on
cardiac pulmonary bypass and active pharmacological
resuscitation and correction of blood gases, etc., multiple
attempts were made to wean him off the cardiopulmonary pass but
were unsuccessful. Heart was
repeatedly going into ventricular fibrillation and could not
maintain any meaningful hemodynamics. Both the right ventricle
and the left ventricle were globally affected. The 3 vein grafts
seemed soft and pliable with no evidence of
occlusion seen externally. The mammary artery, as well, seemed
to be patent. After many hours of resuscitation, finally further
attempts were stopped and the patient was declared.
Medications on Admission:
Lisinopril 20mg po daily
Glipizide 15mg po daily
Metformin 1000mg po BID
SL Nitro 0.4mg SL PRN
Sildenafil 25mg po PRN
Simvastatin 80mg po daily
ASA 81mg po daily
Fish Oil 1000mg po BID
Niacin - unknown dose
Fluticasone 1 spray each nostril daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Three Vessel Coronary Artery Disease
Secondary:
Diabetes
Hypertension
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2175-12-18**]
|
[
"414.01",
"607.84",
"427.5",
"433.10",
"427.41",
"356.9",
"401.9",
"416.8",
"V12.72",
"327.23",
"997.1",
"250.00",
"410.71",
"E878.2",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.91",
"39.61",
"93.90",
"37.23",
"36.13",
"88.56",
"39.64",
"99.60",
"39.65",
"96.04",
"36.15",
"88.72",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
8441, 8450
|
5392, 8115
|
341, 616
|
8573, 8582
|
3689, 5369
|
8635, 8762
|
2498, 2590
|
8412, 8418
|
8471, 8552
|
8141, 8389
|
8606, 8612
|
2605, 3670
|
282, 303
|
644, 1635
|
1657, 2068
|
2084, 2482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,195
| 188,413
|
31291
|
Discharge summary
|
report
|
Admission Date: [**2160-1-14**] Discharge Date: [**2160-1-18**]
Date of Birth: [**2129-7-21**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30 year old female with DM1, ESRD on PD, HTN, p/w DKA. Patient
has been ill for about a week, feeling fatigued and weak. No
fevers but has had chills and rigors. Also has lightheadedness
which she says was worse this morning with standing. Diarrhea
started overnight and she had many episodes of watery stools
without blood. Her BF has had diarrhea also about 1 week ago.
Per VNA- SBP in the mid 90s to low 100s (low for patient). BS
was 471. Patient hadn't been taking good POs. She also endorsed
substernal chest pain which started on day of admission and
resolved before presentation to the floor. Urinates [**Hospital1 **] about 2
ounces normally. She used to miss [**First Name (Titles) 31217**] [**Last Name (Titles) 4319**] but no longer
does so.
.
ROS: Denies fever, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-DM1 (last A1c 10.7%) c/b neuropathy, nephropathy, retinopathy
w/ left eye blindness (followed by Dr. [**Last Name (STitle) **] at [**Last Name (un) **])
-[**Last Name (un) **] resistance
-ESRD on PD (seen by Dr. [**Last Name (STitle) **]
*** [**Last Name (STitle) 1326**] w/u per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - Her pretransplant
workup is complete. She is O positive. CMV and EBV positive,
hepatitis A, B, C and HIV are negative. She has 0% PRA. She had
a normal Pap, normal EKG. Stress test with no reperfusion.
Cardiac echo demonstrated normal EF of 50-60% with some
diastolic dysfunction in left ventricle with no valvular
disease.
-Hypertension
-Hyperlipidemia; TG in the 4000s
-Depression/anxiety
-Lipodystrophy
Social History:
Initially from [**Male First Name (un) 1056**], moved to US 12 years ago. She lives
with boyfriend and her daughter. She does not work outside the
house, she is on disability. She quit smoking over a year ago
but has restarted and is smoking [**2-9**] ppd. She and denies alcohol
or drug use.
Family History:
Her parents are both alive and have diabetes and hypertension.
She has one sister who is obese and has hypertension.
Physical Exam:
Physical exam on MICU admission [**2160-1-14**]:
Vitals - T: 98.3 BP: 123/72 HR: 102 RR: 14 02 sat: 100% RA
GENERAL: A/Ox3, pleasant, appropriate, sitting up in bed talking
on cell phone
HEENT: No icterus. L false eye
CARDIAC: Tachycardic, regular, No MRG
LUNG: CTAB
ABDOMEN: Soft, NT, PD catheter
EXT: Wasting of distal leg muscles
DERM: No rashes
Physical exam on transfer from ICU to floor [**2160-1-16**]:
98.1; 170/103; 99; 15; 98%RA
GENERAL: Comfortable, NAD
HEENT: Normocephalic, atraumatic. No scleral icterus. MMM.
NECK: Supple.
CARDIAC: Tachycardic; normal S1/S2; no murmurs
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: PD catheter in place suprapubic - nonerythematous;
normoactive bowel sounds; soft, nontender
EXTREMITIES: Lower extremity muscle wasting; left DP 1+, right
2+; radial 2+ and symmetric bilaterally
NEURO: A&Ox3; moves all extremities
PSYCH: Listens and responds to questions appropriately
Physical exam on discharge [**2160-1-18**]:
T 98.4 BP 117/79 HR 105 98% RA FSBS 157
GENERAL: Comfortable, NAD, eating without nausea or vomiting
HEENT: Normocephalic, atraumatic. No scleral icterus. MMM.
NECK: Supple.
CARDIAC: Tachycardic; normal S1/S2; no murmurs, rubs or gallops
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: PD catheter in place suprapubic - nonerythematous at
insertion site; normoactive bowel sounds; soft, nontender,
reducible umbilical hernia with mild tenderness
EXTREMITIES: Lower extremity muscle wasting; left DP 1+, right
2+; radial 2+ and symmetric bilaterally
NEURO: A&Ox3; moves all extremities, 5/5 strength in LE
bilaterally
PSYCH: Listens and responds to questions appropriately
Pertinent Results:
Labs on admission [**2160-1-14**]:
WBC-10.6 RBC-3.06* Hgb-10.0* Hct-28.2* MCV-92 MCH-32.7*
MCHC-35.6* RDW-15.4 Plt Ct-267
Neuts-77.5* Lymphs-16.2* Monos-2.6 Eos-3.1 Baso-0.5
Glucose-421* UreaN-98* Creat-12.0*# Na-130* K-3.9 Cl-92*
HCO3-15* AnGap-27*
ALT-11 AST-9 CK(CPK)-73 AlkPhos-63 TotBili-0.2
Lipase-37
cTropnT-0.07*
Albumin-3.6 Calcium-8.8 Phos-12.3*# Mg-1.9
Acetone-NEGATIVE
freeCa-1.01*
Labs on discharge [**2160-1-18**]:
WBC-8.4 RBC-2.64* Hgb-8.1* Hct-24.2* MCV-92 MCH-30.9 MCHC-33.7
RDW-16.1* Plt Ct-266
Glucose-65* UreaN-68* Creat-9.1* Na-135 K-3.5 Cl-98 HCO3-19*
AnGap-22*
Calcium-8.7 Phos-6.3* Mg-1.9
MICRO:
[**2160-1-14**] BCx: NGTD
[**2160-1-14**] MRSA: negative
[**2160-1-15**] Urine: Skin contamination, presumptive Gardnerella
vaginalis
[**2160-1-15**] Dialysis fluid: FLUID CULTURE (Final [**2160-1-18**]):
VIRIDANS STREPTOCOCCI- Isolated from broth media only,
INDICATING VERY LOW NUMBERS OF ORGANISMS.
[**2160-1-15**] Dialysis fluid: no growth
[**2160-1-17**] Dialysis fluid/peritoneal fluid: NGTD
IMAGING:
[**2160-1-14**] CXR: negative
Brief Hospital Course:
30 year-old female with poorly-controlled DM1, ESRD on PD,
hypertension admitted to MICU [**2160-1-14**] with DKA. Prior to
admission to MICU, received NS 800cc and was started on [**Month/Day/Year 31217**]
drip at 6 units per hour.
.
# DKA - In the MICU, DKA suspected to be secondary to viral
gastroenteritis. Initial blood glucose 400-500 with anion gap
23, HCO3 15. No ketonuria. [**Month/Day/Year **] gtt stopped on [**2160-1-15**] and pt
was transferred to the floor. Regular [**Date Range 31217**] restarted at
approximately [**3-13**] of home dose; also started on Humalog sliding
scale per home regimen. Glucose in diasylate adjusted per renal
recs. [**Last Name (un) **] was consulted and her [**Last Name (un) 31217**] was increased back to
her home regimen (Regular U-500 [**2078-9-28**] at breakfast, lunch,
bedtime + Humalog 12 units at dinner + Humalog ISS at dinner)
with actos, which she tolerated well. FSBS on this regimen
fluctuated from 60s-mid 200s. She will follow up with [**Last Name (un) **] for
titration of her outpatient regimen.
.
#. Hypertension: Initially with relative hypotension, then
hypertensive. We increased labetolol to 200mg [**Hospital1 **] with improved
BP control. She was restarted on lisinopril 40mg daily and lasix
80mg daily per home regimen with improved BP control wtih SBP
115-130.
.
#. ESRD: Cr 12 at admission, likely pre-renal due to diarrhea
and decreased PO intake. With IVF, her Cr returned to baseline
~9.0. She was given IP ceftriaxone, vancomycin x1 in ICU and
vancomycin IP x1 on [**2160-1-17**] due to concern for peritoneal
infection with sparse GPC - cultures grew sparse viridans strep.
Vancomycin level at discharge waw 22.4. She will follow up with
her PD nurse on [**2160-1-21**] for further [**Date Range 2742**] of the
infection.
.
#Resltess legs/neuropathy- Continued home regimen of gabapentin
and pramipexole. Pt states she does not take pregabalin so this
was stopped.
.
# Anemia - Hct 24.2 at discharge (baseline 23-26, but was 28 at
admission as pt likely hemoconcentrated given DKA). Likely due
to CKD. No evidence of end organ ischemia. Guaiac negative. She
received epogen 10,000 units on [**2160-1-14**] and 5,000 units on
[**2160-1-18**].
.
# Gardnerella vaginalis - Noted in urine. Pt remained
asymptomatic. Did not to treat as BV resolves spontaneously in
up to [**2-10**] of nonpregnant women. Treatment is indicated for
relief of symptoms in women with symptomatic infection.
.
# Tachycardia - pt was tachycardic throughout admission. Per
OMR, baseline HR is 80s-90s. She did not appear dehydrated on
exam and BP was elevated. She becomes more tachycardic when FSBS
was elevated and SBP was 120s. She remained afebrile, cultures
with sparse growth but no leukocytosis and afebrile making
SIRS/Sepsis unlikely. No A-fib with RVR on EKG. No intervention
this hospitalization, but should be monitored as outpatient.
Medications on Admission:
Per OMR, last reviewed [**2159-12-19**], reviewed with patient
-B Complex-Vitamin C-Folic Acid [Renal Caps] 1mg capsule daily
-Calcitriol 0.5 mcg daily
-Epoetin Alfa [Epogen] 10,000 unit/mL Solution (7500mg weekly)-
given [**2160-1-14**]
-Fluticasone 50 mcg, 1 spray nasal [**Hospital1 **]: PRN congestion
-Furosemide 80mg daily
-Gabapentin 600mg qHS
-[**Hospital1 **] Aspart [Novolog] 100 unit/mL Solution- 12 units at
dinner + Novolog ISS at dinner
-[**Hospital1 **] Regular Humulin R U-500 Concentrated- 500 unit/mL
(Concentrated) Solution: 8 units qAM; 22units qLUNCH, 28units
qHS
-Labetalol 100mg [**Hospital1 **]
-Lisinopril 40mg daily
-Medroxyprogesterone(Contracep) 150 mg/mL Suspension; 150 mg IM
every 12-14 weeks- last given [**2160-1-1**]
-Metoclopramide 5mg QID: PRN nausea
-Nortriptyline 10mg [**Hospital1 **]
-Nortriptyline 30mg qHS
-Ondansetron HCl [Zofran] 8mg TID:PRN nausea
-Oxycodone-Acetaminophen 5-325mg PRN pain from hernia when
lifting heavy objects
-Pioglitazone [Actos] 30mg daily
-Pramipexole [Mirapex] 0.125mg qHS: PRN restless legs
-Pregabalin [Lyrica] 75mg qHS - pt does NOT take this
-Rosuvastatin [Crestor] 40mg daily
-Sevelamer Carbonate [Renvela] 800mg TID with meals, snacks
-Trazodone 100mg qHS: PRN insomnia
-Docusate Sodium [Colace] 100mg [**Hospital1 **]
-Nicotine [NTS Step 1] 21 mg/24 hour patch x1 week- pt states
she didn't take this
-Nicotine [NTS Step 2] 14mg/24 hour Patch xweek 2 and 3, then
stop
ALLERGIES: Bactrim (rash)
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Nortriptyline 10 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
4. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day:
You may take 2 of your 100mg tablets.
Disp:*60 Tablet(s)* Refills:*2*
11. [**Hospital1 **] Regular Hum U-500 Conc 500 unit/mL Solution Sig: As
directed as directed Injection As directed: Take 8 units at
breakfast; take 22 units at lunch; take 28 units at bedtime.
12. Novolog 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous At dinner: Give yourself 12 units of Humalog. Also
use your Humalog [**Hospital1 31217**] sliding scale at dinner.
13. Epoetin Alfa 10,000 unit/mL Solution Sig: 7500 (7500) units
Injection once a week: Pt received 10,000 units on [**2160-1-14**] and
5,000 units on [**2160-1-18**].
14. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
15. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qHS () as
needed for restless legs.
18. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day) as needed for nasal congestion.
19. Medroxyprogesterone(Contracep) 150 mg/mL Suspension Sig: One
[**Age over 90 1230**]y (150) mg Intramuscular every 12-14 weeks: Last
dose given [**2160-1-1**] in clinic.
20. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
21. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
22. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO PRN as
needed for pain: Do not drive, lift heavy objects or drink while
taking this medication.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
Passionate Care Providers Inc
Discharge Diagnosis:
PRIMARY: Diabetic Ketoacidosis
SECONDARY:
Type 1 Diabetes, Uncontrolled with Complications
Lipodystrophy
ESRD on Peritoneal Dialysis
Hypertension
Hyperlipidemia
Peripheral Neuropathy
Anxiety/Depression
Discharge Condition:
Stable, afebrile, FSBS 100s-200s, ambulating, tolerating PO
without nausea
Discharge Instructions:
[**Known firstname 6647**], you were admitted to [**Hospital1 18**] with diabetic ketoacidosis,
likely due to your viral gastroenteritis. Your peritoneal
dialysis was continued in the hospital and you required
antibiotics for an infection. You were able to eat and you were
put back on your home [**Hospital1 31217**] regimen prior to discharge.
Changes to your medications:
1. INCREASE Labetolol 200mg twice a day
2. No changes were made to your home [**Hospital1 31217**] regimen
3. Peritoneal dialysis: 4 exchanges with 6 hour dwell; 2.5%
dextrose solution; 2000ml solution
4. Discuss with your doctor on [**2160-1-22**] if you should increase
your nicotine patch dose (currently at 14mg/24hour patch)
Followup Instructions:
Monday [**2160-1-21**]: Please see [**Doctor First Name 3040**] at the peritoneal dialysis
center as instructed by the renal doctors [**First Name (Titles) **] [**Last Name (Titles) 2742**]. It is
very important that you keep this appointment.
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11712**], NP
Specialty: Diabetes
Date/ Time: Tuesday, [**1-22**] at 10am
Location: [**Hospital **] Clinic, [**Location (un) 551**]
Phone number: [**Telephone/Fax (1) 73808**]
Special instructions for patient: Please call [**Doctor First Name 4248**] at above
number if you need to reschedule.
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2160-1-22**] 2:20
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & PAN
Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2160-1-22**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2160-2-20**] 1:45
|
[
"585.6",
"285.21",
"272.6",
"008.8",
"V49.83",
"357.2",
"250.63",
"272.4",
"250.13",
"403.91",
"999.39",
"250.43",
"V58.67",
"362.01",
"250.53",
"567.29",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
12058, 12118
|
5237, 8136
|
272, 279
|
12365, 12442
|
4153, 5214
|
13196, 14322
|
2347, 2465
|
9657, 12035
|
12139, 12344
|
8162, 9634
|
12466, 12813
|
2480, 4134
|
12842, 13173
|
229, 234
|
307, 1238
|
1260, 2020
|
2036, 2331
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,629
| 162,186
|
2317
|
Discharge summary
|
report
|
Admission Date: [**2126-3-12**] Discharge Date: [**2126-3-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
HPI: [**Age over 90 **] y/o f w h/o htn, afib, heart murmur p/w acute onset of
black tarry diarrhea with red blood last night. Came to hospital
today. No abd pain. Colonoscopy in 97 WNL, according to her. No
prior GI bleeding. [**12-15**] Hct 34%, down to 32% in ED. Denies any
fever/chills/nausea/vomiting/light headedness. No EtOH or recent
NSAID use.
.
In ED HR was ~80 and SBP was stable at 120-130s, she passed
large clots and BRB per rectum while in ED. Her NG lavage was
negative, and her hct continued to drop from 32 to 26% in ED. GI
was called and plan was for tagged RBC scan to localize bleed,
otherwise will do upper and possibly lower endoscopy if
continues to bleed.
Social History:
She lives at an elder living facility. She
does not smoke or drink alcohol. She exercises three times a
week and volunteers at the elder living facility and she is
DNR/DNI.
Family History:
She has a son who had renal disease to whom she donated her
kidney, but died at age 36
Physical Exam:
PE: HR 92, BP 110/72 R 18 sat 98% RA
gen: alert, OX3, appears 10-20 years younger than her stated age
HEENT: mmm, no JVD, no LAD, no icterus
CV: RRR 3/6 sys cresc-decresc m at RUSB and [**4-15**] holosys m at
apex
pulm: CTAb
abd s/nt/nd +BS
ext 1+ pedal edema bilat, no palp pulses but warm and
dopplerable bilat
rectal: BRB
Pertinent Results:
[**2126-3-12**] 03:17PM WBC-6.3 RBC-2.92* HGB-9.6* HCT-26.9* MCV-92
MCH-32.7* MCHC-35.6* RDW-14.6
[**2126-3-12**] 03:17PM NEUTS-59.4 LYMPHS-33.9 MONOS-5.5 EOS-0.3
BASOS-0.9
[**2126-3-12**] 03:17PM PLT COUNT-202
[**2126-3-12**] 11:15AM HGB-11.5* calcHCT-35
[**2126-3-12**] 11:00AM GLUCOSE-113* UREA N-31* CREAT-1.1 SODIUM-139
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2126-3-12**] 11:00AM WBC-6.3 RBC-3.49* HGB-11.4* HCT-32.4* MCV-93#
MCH-32.5* MCHC-35.1* RDW-14.6
[**2126-3-12**] 11:00AM NEUTS-54.1 LYMPHS-39.4 MONOS-5.7 EOS-0.4
BASOS-0.5
[**2126-3-12**] 11:00AM PLT COUNT-218
[**2126-3-12**] 11:00AM PT-13.6* PTT-27.3 INR(PT)-1.2*
NG tube: clear yellow
Brief Hospital Course:
A&P; [**Age over 90 **] yo s/p GI bleed now with stable HCT. Colonoscopy today
revealed diverticulosis.
.
GIB: A colonoscopy revealed a sessile 2 cm polyp 15 cm into the
rectum, and a few mild nonbleeding diveritula in the descending
colon. She was transfused 3 units of PRBC after an initial
hematocrit drop from 32 to 26 in the Emergency Department. A
tagged red blood cell scan did not identify a source of the
bleed. She was started on protonix and asprin was held. She
was hemodynamically stable at time of discharge, and was
scheduled for a flexible sigmoidoscopy in one month.
.
CV: She remained in normal sinus rhythm, she had normal left
ventricular function by TTE in [**2120**], atenolo and diazide were
held while she was hemodynamically unstable, her blood pressure
medications were reinitiated at time of discharge. Her aspirin
was held and she was to discuss with her PCP prior to restarting
her aspirin.
FEN: Initially NPO then advanced to
Access: 2 PIVs
Code: DNR/I
Ppx: pneumoboots, PPI
Medications on Admission:
1. Atenolol 25 mg one po q day
2. Triamterine/Hydrochlorothiazide 37.5/25 mg one po q day
3. Aspirin 81 mg po q day
Discharge Medications:
1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. [**First Name5 (NamePattern1) 4886**] [**Last Name (NamePattern1) 12106**] Sig: One (1) [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 12107**]. One.
Disp:*1 [**Last Name (NamePattern1) **]* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticula
Polyps
Discharge Condition:
Good
Discharge Instructions:
If you experience additional blood per your rectum, dizziness,
chest pain, shortness of breath or any other concerning symptoms
please call your doctor.
You will require another sigmoidoscopy in [**2-11**] months by your
gastroenterologist
Please take your medications as instructed
Please do not take your aspirin until told to by your PCP
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 1730**] [**Name Initial (NameIs) **].,[**Name Initial (NameIs) **] [**Hospital **] [**Hospital 11099**] CLINIC
Date/Time:[**2126-4-3**] 12:30
Provider: [**Name10 (NameIs) **],ROOM GI ROOMS Date/Time:[**2126-4-3**] 12:30
|
[
"401.9",
"585.9",
"276.51",
"562.12",
"569.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
4010, 4016
|
2364, 3384
|
269, 285
|
4079, 4086
|
1653, 2341
|
4478, 4753
|
1203, 1291
|
3550, 3987
|
4037, 4058
|
3410, 3527
|
4110, 4455
|
1306, 1634
|
223, 231
|
313, 997
|
1013, 1187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,111
| 143,962
|
50167
|
Discharge summary
|
report
|
Admission Date: [**2159-6-11**] Discharge Date: [**2159-6-14**]
Date of Birth: [**2074-7-24**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
fevers, hypoxia, hypotension and positive blood culture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 YO M w MMP including ESRD on HD, CAD, PPM for [**First Name3 (LF) **]-brady,
PVD with ulcers who was brought in by EMS after being noted to
have fevers, a sat of 84%, BP 84/55 and positive blood cultures
(Proteus mirabilis; [**1-8**] drawn on [**6-6**]) from his nursing home. The
patient is a relatively poor historian and is unable to provide
much medical history. Per his HCP, his mental status has
decresead dramatically over the past year. More recently, he has
had hallucinations, abd bloating and increased LE pain and
ulcerations. He was seen on [**6-7**] by vascular surgery who started
him on levaquin due to concern for superinfection of his LE
ulcers. He returned to his nursing home where the staff felt
levaquin was not dosed properly and stopped levaquin. His abx
were changed to ceftriazone 1g IV daily which were given on [**6-9**]
and 1g on [**6-10**]. The delay in receiving ctx was due to lack of IV
access. A PIV was eventually placed for abx but he self-removed
it on [**6-10**] pm.
.
Upon presentation to the ED, his initial VS: 98.5 62 83/52 30
88% RA ---> 100% on a NRB. Exam sig for orientation time 1,
crackles at bases and abdominal distention. EKG reportedly at
his baseline with NAD, Nl int, ST dep V2-V3, TWI diffusely. Labs
notable for lactate 2.6 and WBC 11.8, trop 0.18. He was not
given any fluid due to concern for worsening his respiratory
status. Renal was called to evaluate the patient for urgent HD.
He was given vanc 1g and levaquin 750mg IV. In regards to
access, he has 1 PIV and an AV fistula. His VS at time of ED
sign out were: 93 73/38 --> 109/65 25 100% on NRB.
.
Review of sytems:
Patient is a poor historian. He reports pain in his left leg and
shortness of breath. He is able to deny chest pain, weakness,
abdominal pain.
Past Medical History:
- CAD s/p CABG (anatomy unknown) patient reports was 20 years
ago
- AFib
- s/p PPM - [**2157**] ?[**Year (4 digits) **]-brady
- HTN
- Hyperlipidemia
- CHF - diastolic dysfunction; [**11/2158**] TTE EF 65-70%, elevated
PCWP, RVH and RV dilation/HK with severe pulmonary hypertension.
1+ MR, mild AS.
- Pulmonary hypertension - TR gradient 55-60 with RV dysfunction
by TTE [**11/2158**]
- PVD s/p multiple bypasses and most recently R SFA stent on
[**2159-2-8**]
- ESRD with multiple BUE AVF's and grafts. HD MWF
- Hypothyroidism
- Celiac disease
- Osteoporosis
- GERD
- Depression
- S/p right endoscopic carpal tunnel release on [**2159-2-27**]
- S/p third and fourth flexor tenosynovitis neurectomy on
[**2159-2-27**]
- S/p multiple abdominal surgeries including colon extension
- H/o "infected gallbladder"
Social History:
He was living at Newbridge on the [**Doctor Last Name **]. He was widowed 7
years ago and has two daughters, both of whom live out of state.
He managed a plastics manufacturing plant. Drinks occasional
wine and has a 10 year history of pipe smoking and smoked a
cigarette per day for 5-10 years.
Family History:
Mother died of "cancer under the armpits" at age 73. Father
died of PNA at age 47 just before sulfa drugs available; 1
brother died of lung cancer; one brother died of CV disease
Physical Exam:
Vitals: Not recorded
GENERAL: Chronically ill male NAD
HEENT: oropharynx clear, dry membranes
NECK: distended external jugular veins
CHEST: crackles bibasilarly, no wheezes
CV: S1 S2 regular rhythm
ABD: positive bowel sounds, NT, distended
EXT: warm, distal pulses intact, air boot on left LE with
dressing C/D/I, dressing on left wrist C/D/I
Pertinent Results:
Admission labs
[**2159-6-11**] 12:11PM BLOOD WBC-11.8*# RBC-3.95* Hgb-12.8* Hct-39.9*
MCV-101* MCH-32.4* MCHC-32.1 RDW-15.5 Plt Ct-247
[**2159-6-11**] 12:11PM BLOOD Neuts-85.7* Lymphs-5.5* Monos-7.3 Eos-0.5
Baso-1.1
[**2159-6-11**] 12:11PM BLOOD PT-13.3 PTT-25.8 INR(PT)-1.1
[**2159-6-11**] 12:11PM BLOOD Glucose-115* UreaN-68* Creat-5.8*# Na-141
K-4.8 Cl-96 HCO3-31 AnGap-19
[**2159-6-11**] 12:11PM BLOOD Glucose-115* UreaN-68* Creat-5.8*# Na-141
K-4.8 Cl-96 HCO3-31 AnGap-19
[**2159-6-11**] 12:11PM BLOOD Calcium-8.3* Phos-3.3 Mg-1.7
[**2159-6-11**] 03:56PM BLOOD Type-ART pO2-207* pCO2-42 pH-7.43
calTCO2-29 Base XS-3
[**2159-6-12**] 05:10PM BLOOD Type-ART pO2-115* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
[**2159-6-11**] 12:30PM BLOOD Glucose-108* Lactate-2.6* K-4.5
[**2159-6-13**] 06:07AM BLOOD Lactate-1.9
[**2159-6-12**] 06:31AM BLOOD VitB12-1383*
[**2159-6-12**] 06:31AM BLOOD TSH-5.4*
[**2159-6-13**] 05:52AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.3
[**2159-6-12**] 06:31AM BLOOD CK-MB-9 cTropnT-0.19*
[**2159-6-11**] 12:11PM BLOOD cTropnT-0.16* proBNP-GREATER TH
[**2159-6-12**] 09:30PM BLOOD CK-MB-8 cTropnT-0.16*
[**2159-6-13**] 05:52AM BLOOD Glucose-108* UreaN-58* Creat-5.4* Na-139
K-5.2* Cl-94* HCO3-26 AnGap-24*
[**2159-6-13**] 05:52AM BLOOD WBC-10.9 RBC-3.65* Hgb-12.0* Hct-37.6*
MCV-103* MCH-32.8* MCHC-31.9 RDW-15.4 Plt Ct-267
Blood cx: NGTD
Brief Hospital Course:
84M with multiple medical problems including [**Name2 (NI) **]-brady
syndrome, asymptomatic hypotension, diastolic CHF, pulmonary
hypertension, ESRD on HD presenting from hemodialysis with
asymptomatic hypotension and hypoxia in the setting of positive
blood cultures. He was admitted to the ICU and started on
vancomycin, zosyn, and levofloxacin to cover for possible soft
tissue (LE ulcer) and respiratory sources (aspiration PNA).
Blood cultures here have been negative. He was seen by the renal
service and underwent UF/HD (last done [**6-12**]). Per his daughter he
is chronically ill and has been deteriorating clinically over
the past year. Given the abscence of clinical improvement and
overall limited quality of life, escalation of care was not felt
to be consistent with the patient's wishes. A family meeting was
held and given the patient's poor prognosis he was made CMO. He
expired on [**2159-6-14**] at 11:13PM.
Medications on Admission:
tylenol standing and prn
allopurinol 100mg daily
amiodarone 200mg daily
aspirin EC 81 mg daily
calcium acetate 650mg TID
plavix 75 mg daily
levothryoxine 300mg PO daily
metoprolol 12.5 mg TID
midodrine 5mg PO TID
protonix 20mg PO daily
senna
simvastatin 20mg PO qhs
tramadol 25mg PO BID
nephrocaps
pepto-bismol/kaopectate 262 mg q4h prn diarrhea
miralax
simethacone
ambien 2.5mg qhs prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypotension
Bacteremia
Hypoxia
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
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71,707
| 175,959
|
48914
|
Discharge summary
|
report
|
Admission Date: [**2144-1-20**] Discharge Date: [**2144-2-3**]
Date of Birth: [**2089-4-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vancomycin Analogues /
Gentamicin / Ciprofloxacin Hcl / Cefazolin / Benadryl /
Opioids-Morphine & Related
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
Right arm AV graft - [**2144-1-29**] by Dr. [**First Name (STitle) **]
History of Present Illness:
54F w/ hx of ESRD s/p renal transplant x 3, PE on coumadin
anticoagulation, HTN, hep C p/w epistaxis and elevated
creatinine. Since she has started anticoagulation she has
experienced now 3 nosebleeds. 2 of these bleeds were
approximately 2 weeks ago and short duration (< 10 min) but
today starting at 2PM she experienced a persistent episode of
epistaxis refractory to patient's own attempt at direct
pressure. On presentation to the ED she was found to have INR
elevated to 15.7 and hematocrit decrease of 8 points compared to
[**1-2**]. She otherwise has been well although she does complain of
fatigue over the past several months. She denies any
light-headedness, syncope, fever, chills, chest pain, dyspnea,
nausea, vomiting, abdominal pain or dysuria. She states her
urine output has not decreased acutely over the past several
weeks, and in particulary denies any pain over her renal
transplant. She does have dark stool, but takes iron.
.
Of note she does complain of pain on the plantar surface of her
left foot that is new onset today. She noticed this pain when
she woke up this morning and denies any recent traumatic injury.
She also describes painful "lumps" along the posterior aspect of
her thighs bilaterally.
.
In the ED, initial VS were: 99.5 75 102/69 16 100% RA. She was
given 2 units FFP and vitamin K 10mg IV. Renal transplant was
contact[**Name (NI) **] and will see the patient on [**1-21**] during the day. She
was T&C for 2 units, but no blood was given in the ED. She was
noted as a difficult stick but her portacath was being used for
access.
.
On arrival to the MICU, she continued to complain of fatigue,
but otherwise felt well. She does have the pain along the
plantar surface of her left foot where she has a small hematoma.
.
Review of systems:
- negative except as noted in HPI
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. End-stage renal disease (due to RPGN, baseline creatinine
previously in the 2.1-2.2 range; now since [**6-/2143**] has been
between 4.2-5, plans for new access establishment for possible
future permanent HD needs; s/p renal transplantation x 3 (two
failed transplant attempts), LRRT in [**2117**] (from brother), s/p
DCD in [**2120**] and [**2130**] due to chronic allograft nephropathy
(biopsy [**9-/2138**])
2. Hypertension
3. GERD
4. Anemia of chronic disease
5. s/p gastric bypass surgery (had prior diabetes mellitus type
2 which was improved by the surgery)
6. Hepatitis C (secondary to blood transfusions)
7. Sinus bradycardia
8. s/p parathyroidectomy
9. s/p left chronic knee pain (following injury), s/p lumbar
sympathetic block to limit pain on [**2143-8-18**] at pain clinic
10. Neuropathic foot pain (unclear etiology)
11. Spina bifida occulta
12. Chronic tension headaches
13. Fecal and urinary incontinence
14. Recurrent urinary tract infections
15. Osteopenia
16. s/p ventral hernia repair ([**9-/2139**]) - with Marlex mesh
17. s/p partial excision of left upper arm AV-graft and right
upper arm AV-graft
Social History:
Lives with boyfriend. Not currently employed. Denies tobacco use
or alcohol use; no recreational substance use.
Family History:
Father with lung cancer, maternal grandmother with [**Name2 (NI) 499**] cancer
and stroke. Siblings with HTN and ESRD, DM, hypothyroidism.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: MMM, 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: multiple surgical scars, soft, non-tender,
non-distended
GU: no foley
Skin: several small areas of ecchymosis along her legs, plantar
surface of foot
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, several small, mobile nodules TTP bilaterally along
posterior thigh
L foot: TTP along plantar surface w/ small hematoma
Neuro: Grossly intact
Rectal: noted to be trace heme positive on stool guiac
Pertinent Results:
Admission Labs:
[**2144-1-20**] 07:45PM BLOOD WBC-9.1 RBC-3.18* Hgb-8.5* Hct-25.4*
MCV-80* MCH-26.8* MCHC-33.5 RDW-16.3* Plt Ct-314#
[**2144-1-20**] 07:45PM BLOOD Neuts-90.8* Lymphs-7.1* Monos-1.9*
Eos-0.1 Baso-0.1
[**2144-1-20**] 07:45PM BLOOD PT-150 PTT-138.8* INR(PT)-15.7*
[**2144-1-20**] 07:45PM BLOOD Glucose-121* UreaN-127* Creat-8.6*#
Na-142 K-4.4 Cl-105 HCO3-12* AnGap-29*
Pertinent Labs:
CXR: IMPRESSION: No acute cardiopulmonary abnormality.
Renal US: IMPRESSION:
1. No hydronephrosis.
2. Patent renal vasculature. Mildly elevated resistive indices
up tp 0.84
slightly increased (previously highest measurement 0.77)
C diff toxin screen: Feces negative for C.difficile toxin A & B
by EIA.
Urine Culture [**2144-1-22**]: URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Discharge Labs:
Brief Hospital Course:
Primary Reason for Hospitalization:
54F w/ hx of renal transplant x 3, recent PE diagnosis on
coumadin, HTN, hep C presented with epistaxis in setting of
supratherapeutic INR, acute on chronic renal failure, admitted
to the ICU for initial monitoring, experienced recurrent
epistaxis on othe floor after re-initiating anticoagulation.
.
Active Issues:
.
# Epistaxis/Supratherapeutic INR:
The patient was found to have epistaxis in setting of elevated
INR to 15.7, found to have eight point hematocrit drop, nadir of
19.5. Anterior packing was done in the ED and on arrival to the
MICU, the patient was no longer bleeding. She received FFP and
vitamin K in the ED for reversal of her anticoagulation. While
in the MICU, the patient was transfused 2U PRBC with appropriate
hematocrit response. Her coumadin was held. Renal transplant
team felt supratherapeutic INR was most likely due to drug
interactions (coumadin, sirolimus). The packing was kept in for
4 days, and coumadin was re-started with a heparin bridge on day
3 of packing. Clindamycin used for Toxic Shock Syndrome
prophylaxis. She experienced recurrent epistaxis about 36 hrs
after packing was removed, with INR 2.0 and therapeutic PTT,
required 1u pRBC transfusion. Left nostril was repacked by ENT
on [**1-26**]; right nare was also noted to have bleeding, though ENT
was unable to localize, controlled with surgifoam and afrin.
There were intermittent maroon-colored stools secondary to
epistaxis. On [**1-31**] her L nare packing was removed. Her Hct
remained stable and she had no recurrence of epistaxis. On
[**2-1**] she was started on IV heparin and restarted on coumadin
2mg daily (of note, IV heparin not started to bridge her to
coumadin, but rather to monitor whether she would have
recurrence of bleeding once anticoagulated). She did well
without recurrence of bleeding, and on [**2-2**] IV heparin was
stopped. On day of discharge her INR was 1.3. She should have
her INR monitored very closely after discharge. She will be
monitored by the [**Company 191**] coumadin clinic.
.
# Acute on Chronic Renal failure:
The patient is s/p kidney transplant x3, again with failing
graft. Most recent creatinine range from 4 to 5 over past
several months, elevated to 8.6 on presentation, though returned
to baseline during hospitalization. Ultrasound showed no
hydronephrosis with patent vessels. The patient's
spironolactone and lasix were held. She had no signs of uremia
or need for urgent dialysis, though she will likely need to
re-initiate dialysis in the next two months. Transplant surgery
placed AV graft in RUE on [**1-29**]. Nylon stitches to come out at
followup with Dr. [**First Name (STitle) **] on [**2144-2-20**]. On discharge, her
creatinine was stable at 4.5.
Sirolimus was initially held on admission in setting of
potential interaction with warfarin, but was restarted at 2mg
daily on floor with appropriate sirolimus level. She was
continued on home dose prednisone 5mg daily. She was advised to
restart her home lasix dose but to continue holding her
spirinolactone due to her risk of hyperkalemia with her
worsening renal failure. She is scheduled to follow up with Dr.
[**Last Name (STitle) 7473**] in nephrology clinic.
.
# Pulmonary Embolism:
Ms. [**Known lastname 102620**] has been anticoagulated with coumadin for a
pulmonary embolism diagnosed in [**2143-11-2**]. Anticoagulation
was reversed with 2 units of FFP and 10mg of vitamin K due to
severe epistaxis as described above. Her INR was 1.2 on [**1-23**]
when coumadin (bridged with IV heparin) was restarted. After
recurrent epistaxis episode [**1-26**], she was given another 1u FFP
and 2mg po vitamin K. No further bleeding noted, and she was
restarted on coumadin on [**2144-2-1**]. She was discharged on 2mg
coumadin daily (no bridge). Her INR was 1.3 on discharge, and
she will have her INR monitored closely by the [**Hospital 191**]
[**Hospital3 **].
.
# Hypocalcemia
Secondary to hypoparathyroidism after parathyroidectomy in past.
Her calcitriol was increased from 0.25mcg daily to 0.5mcg
daily. She was continued on calcium carbonate supplements.
.
# Left lateral foot pain:
Small area of ecchymosis w/ hematoma on left lateral surface.
Patient does not remember any recent trauma, but in setting of
elevated INR minor inciting injury could be causative factor.
Xrays show no fracture. Pain was worsened with walking but
improved by time of discharge.
.
# Posterior thigh pain w/ painful nodules:
On exam small, mobile nodules palpated along bilateral posterior
thighs just deep to the subcutaneous tissue. Reproducible pain
on palpation of these nodules. Differential includes lipoma,
hematoma, lymphadenopathy. Likely lipomas, but will need to be
followed for interval changes. As these did not enlarge as an
inpatient, their evaluation can likely be deferred to the
outpatient setting.
.
# Hypertension:
Ms. [**Known lastname 102729**] home diltiazem, labetalol, lasix, and
spirinolactone were held during her hospitalization. Upon
transfer to the floor, her blood pressure was controlled with
amlodipine 10mg daily. Lasix and spironolactone were not
restarted as she remained euvolemic. Upon discharge she should
restart her home lasix dose, but should continue to hold her
spirinolactone as it increases her risk of hyperkalemia with her
worsening renal failure.
.
# UTI:
Ms. [**Known lastname 102620**] was discovered to have a grossly positive UA on
[**2144-1-22**], cultures grew Klebsiella and Proteus. She was treated
with a 10 day course of Ceftriaxone.
.
Chronic Issues:
# GERD:
The patient was continued on home omeprazole.
.
# Chronic pain:
Per history has bilateral knee pain, some neuropathic foot pain.
She was continued on her home oxycodone, lidocaine patch,
cyclobenzaprine as needed.
.
# Transitional issues:
- Medication changes: diltiazem, labetolol, and spirinolactone
were discontinued, she was started on amlodipine for blood
pressure control, sirolimus was decreased from 2.5mg daily to
2mg daily, calcitriol was increased from 0.25mcg daily to 0.5mcg
daily.
- She is scheduled to follow up with Dr. [**First Name (STitle) **] (transplant
surgery) and Dr. [**Last Name (STitle) 4883**] (nephrology). She is asked to also
follow up with her primary care physician [**Name Initial (PRE) 176**] 1-2 weeks of
discharge.
- She was restarted on coumadin 2mg daily on [**2-1**] without a
bridge. Her INR should be monitored every other day for at
least the first week. Her INR will be monitored by the [**Hospital 191**]
[**Hospital3 **].
- She maintained full code status throughout her
hospitalization.
Medications on Admission:
- multivitamin
- loperamide 2mg TID for loose stools
- prednisone 5mg daily
- pantoprazole 40mg [**Hospital1 **]
- labetalol 50mg QAM, 100mg QPM
- folic acid 1mg daily
- lasix 20mg daily
- calcitriol 0.25mcg daily
- clonazepam 0.5mg QHS prn anxiety
- diphenoxylate-atropine 2.5-0.025 mg Q6hrs for loose stools
- prochlorperazine maleate 5 mg Q6hrs for nausea
- hydroxyzine HCl 25 mg twice daily for pruritis
- acetaminophen 500-1000mg Q8hrs for pain
- spironolactone 25mg daily
- lidocaine 5% (700mg/patch) topically daily
- cyclobenzaprine 10 mg TID for pain, muscle spasm
- sodium bicarbonate 650mg twice daily
- oxycodone 5mg Q6hrs for pain
- sirolimus 2.5mg daily
- warfarin 3mg on Monday and Saturday, 2mg all other days
- calcium carbonate 200 mg calcium QID
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) as needed for loose stool.
3. prednisone 5 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 Q12H (every 12 hours).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
8. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO QID (4 times a day).
9. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for itching.
11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times
a day as needed for pain.
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain: [**Month (only) 116**] cause drowsiness. Do not
drive or operate machinery while taking.
14. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
16. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
19. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
20. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*0*
21. darbepoetin alfa in polysorbat 40 mcg/0.4 mL Syringe Sig:
One (1) injection Injection q3 weeks.
22. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Nosebleed (epistaxis)
Recent Pulmonary Embolism
Hypertension
Chronic Kidney Disease stage 5
Hepatitis C
Osteopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 102620**],
You were admitted to the hospital because you were having a lot
of bleeding from your nose. You received blood transfusions and
your nose was packed for a few days to stop the bleeding. You
were also given antibiotics for your urinary tract infection.
You have been restarted on your coumadin for the blood clot in
your lungs. You should have your coumadin levels monitored very
closely after you leave the hospital. If you have any signs of
bleeding that concern you, please be sure to return to the
Emergency Department.
You had an AV Graft placed by the Transplant Surgery team while
you were here. The nylon stitches will come out at your
followup appointment.
We made the following changes to your medications while you were
in the hospital:
-STOP labetolol
-STOP spirinolactone
-CHANGE sirolomus from 2.5mg daily to 2mg daily
-CHANGE calcitriol from 0.25mcg daily to 0.5mcg daily
-START amlodipine 10mg daily
We made no other changes to your medications. Please continue
taking the rest of your medications as prescribed by your
providers.
We have scheduled appointments for you to follow up with Dr.
[**First Name (STitle) **] in the transplant surgery clinic and Dr. [**Last Name (STitle) 4883**] in the
nephrology clinic. We would also like you to see you primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5781**], within 1-2 weeks of leaving the
hospital. Please call [**Telephone/Fax (1) 250**] to schedule.
It was a pleasure taking care of you at [**Hospital1 18**] and we wish you a
speedy recovery.
Followup Instructions:
You have the following appointments scheduled at [**Hospital1 18**]:
Department: TRANSPLANT CENTER
When: THURSDAY [**2144-2-13**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2144-2-26**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2144-5-26**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
|
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"339.12",
"584.9",
"041.3",
"924.20",
"784.7",
"252.1",
"403.91",
"599.0",
"787.60",
"276.2",
"E933.1",
"255.41",
"787.91",
"285.1",
"530.81",
"428.0",
"355.8",
"E934.2",
"V12.51",
"276.0",
"444.21",
"756.17",
"788.30",
"070.70",
"E928.9",
"V45.86",
"996.81",
"582.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.03",
"39.27",
"21.01"
] |
icd9pcs
|
[
[
[]
]
] |
14994, 15053
|
5461, 5798
|
409, 482
|
15212, 15212
|
4502, 4502
|
16981, 18111
|
3655, 3795
|
12895, 14971
|
15074, 15191
|
12105, 12872
|
15363, 16958
|
5438, 5438
|
3810, 4483
|
2293, 2329
|
11302, 12079
|
360, 371
|
5813, 11016
|
5274, 5419
|
510, 2274
|
4518, 4885
|
15227, 15339
|
4901, 5239
|
11280, 11282
|
11032, 11257
|
2351, 3509
|
3525, 3639
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,252
| 157,464
|
55065
|
Discharge summary
|
report
|
Admission Date: [**2154-9-5**] Discharge Date: [**2154-9-9**]
Date of Birth: [**2076-11-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 46126**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**2154-9-5**] EGD
History of Present Illness:
Patient is 77 patient s/p Hartmann's for perforated
diverticulitis ([**2154-5-3**] at [**Hospital1 3278**]) and recently admitted on ACS
from [**Date range (2) 112382**] for perforated diverticulitis at her
colostomy site for which she underwent revision colostomy and
left hemicolectomy. She had been discharged to rehab on [**2154-8-27**]
doing relatively well, although with some minimal PO intake.
Today she felt very weak around 5pm with associated sweats. No
fevers or chills. Following this, frank dark blood came out of
her ostomy. Her hematocrit was 23 down from 28. She was
transferred to [**Hospital1 **] for further management of GI bleed.
Past Medical History:
PMH:
- HTN
- hypercholesterolemia
- hypothyroidism
- perforated diverticulitis
PSH:
[**2154-5-3**] Hartmann's
[**2096**] - presacral neurectomy
Social History:
non-smoker, social etoh - few times a week, no illicit drugs
Family History:
non-contributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
VS: 97.6 98 123/48 16 100% Room air
Gen: NAD, AOX3
CV: RRR
Resp: CTAB
Abd: Colostomy with visible melena and dark blood. Mucus fistula
in tact. Midline incision with fibrinous exudate
Pertinent Results:
[**2154-9-5**] 04:52PM GLUCOSE-96 UREA N-22* CREAT-0.4 SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-27 ANION GAP-11
[**2154-9-5**] 04:52PM CALCIUM-7.7* PHOSPHATE-2.8 MAGNESIUM-1.7
[**2154-9-5**] 12:03PM HCT-27.8*
[**2154-9-5**] 08:30AM HCT-26.9*
[**2154-9-7**] 07:15AM BLOOD WBC-6.0 RBC-2.95* Hgb-8.4* Hct-26.1*
MCV-89 MCH-28.6 MCHC-32.3 RDW-14.9 Plt Ct-344
[**2154-9-7**] 01:00PM BLOOD Hct-28.3*
[**2154-9-8**] 07:30AM BLOOD Hct-27.9*
Brief Hospital Course:
She was admitted to the Acute Care Surgery service and
transferred to the ICU. She received 3u of pRBC prior to
admission to ICU. Gastroenterology was consulted. She was
intubated and sedated for airway protection in preparation for
the EGD. An EGD was performed which showed multiple duodenal
ulcers (4 total) which showed evidence of recent bleed. These
were all injected with epinephrine and hemostasis was achieved.
Protonix IV BID was started. She was kept intubated overnight in
anticipation of repeat EGD the next day to evaluate her ulcers.
She was stable overnight and her hematocrit remained stable
around 25 and there was no further need for EGD. She was
extubated successfully on [**9-6**]. She was alert and responsive
after extubated. She did not require any pressors and was
saturating well on room air. She was started on a clear liquid
diet post-extubation, which she tolerated well. She was stable
to be transferred to the floor subsequently.
Once transferred to the floor her hematocrits continued to be
followed closely. They remained low but were stable - her
discharge hematocrit was 27.9. Further recommendations from GI
included holding anticoagulation initially and avoiding NSAID's.
Once her hematocrits stabilized subcutaneous Heparin was
started. She will require outpatient EGD in about 4-6 weeks as
scheduled. She was continued on Protonix [**Hospital1 **] which was changed
to oral form prior to discharge.
She was discharged to rehab with appointments in place for her
follow up with Acute Care Surgery and with Gastroenterology.
Medications on Admission:
ASA 81', levoxyl 25', cardura 2'', centrum MV, lasix 40',
simvastatin 40'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain [**1-23**]
2. Heparin 5000 UNIT SC TID
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Ondansetron 4 mg IV Q8H:PRN nausea
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain [**5-28**]
6. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with bleeding in your
gastrointestinal tract and was found to have several ulcers in
your duodenum. Your blood counts were followed closely and are
expected to be low but have been stable. You are being treated
with a class of medications called proton pump inhibotors or
PPI's which will need to be continued as directed.
**DO NOT TAKE ASPIRIN OR ANY NSAID'S SUCH AS MOTRIN, IBUPROFEN,
ALLEVE, NAPROSYN AS THESE MEDICATIONS PUT YOU AT RISK FOR
FURTHER BLEEDING IN YOUR GI TRACT
It is important that you follow up with your gastroenterologist
Dr. [**First Name (STitle) 908**] as scheduled in the next several weeks.
Followup Instructions:
Department: GI-WEST PROCEDURAL CENTER
When: TUESDAY [**2154-10-15**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST PROCEDURAL CENTER
When: TUESDAY [**2154-10-15**] at 12:30 PM
With: WPC ROOM THREE [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: MIKHAEL-[**Doctor Last Name **],THARWAT A
Address: [**Street Address(2) 72901**], [**Location (un) **],[**Numeric Identifier 72902**]
Phone: [**Telephone/Fax (1) 63184**]
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2154-9-24**] at 4:30 PM
With: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**]
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2154-9-11**]
|
[
"401.9",
"V44.3",
"244.9",
"285.1",
"532.40",
"V45.72",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"38.91",
"96.04",
"38.97",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4004, 4075
|
2036, 3602
|
312, 333
|
4142, 4142
|
1565, 2013
|
5003, 6390
|
1281, 1300
|
3726, 3981
|
4096, 4121
|
3628, 3703
|
4325, 4980
|
1315, 1546
|
264, 274
|
361, 1015
|
4157, 4301
|
1037, 1184
|
1201, 1264
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,275
| 185,278
|
43673
|
Discharge summary
|
report
|
Admission Date: [**2135-12-2**] Discharge Date: [**2135-12-4**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 57 year-old man with history of ESRD on HD,
long seizure history and diastolic chf admitted after grand mal
seizure, intubation for airway protection and hypoxic
respiratory failure. Patient in USOH on his keppra and lamictal
until this AM when he had witnessed 1 minute grand mal seizure.
Patient was post-ictal, EMS was activated and brought to ED. In
ED, agitated, had negative head CT and then desatted to 70's.
Intubated for airway protection and hypoxic respiratory failure.
Concerning patient's seizure history, last gm seizure about 6
months ago as per family, but has had occasional non-convulsive
seizure as well more recently. Seizures had been well-controlled
until roughly 4 years ago when depakoate was discontinued due to
elevated ammonia levels. More recnetly, patient on lamictal and
keppra with good control, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**]. With
respect to possible toxic-metabolic causes: Patient on HD,
uremia likely lowering threshold. Also, consider infection but
patient without significant localizing symptoms as per family.
No pain, does have mild cough. LFT's within normal limits,
finger stick normal in ED and sugar by chem-7's normal.
Concerning his recent resp history: Patient suffered mechanical
fall on [**10-31**] with trauma to left chest wall with negative CXR,
CT head. Since that time he has had increasing sob, doe but
there is no clear objective mech cause for his sob, doe. After
this he was started on home oxygen, echo on [**11-1**] showed ef of
40% with 1-2+MR. [**Name13 (STitle) **] has needed to have increasing amounts of
volume removed with dialysis over this time which has been
limited by hypotension. He was admitted on [**11-19**] for what
appeared to be heart failure, was diuresed with HD, left AMA on
[**11-21**] before repeat echo obtained. Negative CTA at that time.
Family reports patient sob, using home oxygen intermittently
since discharge.
In the MICU, the patient was diuresied 5.5L over 2 days. He was
intubated on arrival and this was removed the following day,
with the patient now oxygenating well on NC. He was seen by
neurology who put him on an ativan taper, increased his lamictal
to 200BID and continued his keppra.
Past Medical History:
seizures since childhood, which began as generalized
tonic-clonic. He was treated with phenobarbitol and Mysoline.
Later, was changed to Depakote and Dilantin. Depakote was
discontinued roughly 4 years ago due to elevated ammonia levels.
Since, then his seizures have increased in frequency and
severity. As a result, muliple medications inculding Lamictal,
Trileptal, Tegretol and Keppra have been tried and he has most
recently been on combination of Keppra and Lamictal. His
seizures have been occuring about once every 1-2 months. Usual
episodes are
characterized by confusion and disorientation with rare,
generalized tonic clonic episodes. As per OMR notes, he has a
history of non-convulsive status which presented as confusion in
the past and responded to ativan.
-ESRD on HD, due to idiopathic glomerulonephritis, s/p two
failed renal transplants
-hypertension
-hypothyroidism
-peripheral [**Month/Year (2) 1106**] disease
-hypoparathyroidism
-hepatitis C
-CHF-diastolic dysfunction (EF>30% in [**4-/2135**])
-SVT/AVNRT s/p ablation
-multiple fistulas
-H/O MRSA line infection
Social History:
Smoked since he was young, per son, since he was 17-18 y/o.
Used to smoke heavier, now weaned to [**2-13**] ppd, No alcohol or
IVDA. Has been on disability since [**2115**].
Family History:
mother with breast CA
father alive, with CAD, CHF
sons-healthy
Physical Exam:
General: Sitting up eating in bed, NAD
HEENT: PERLLA, MMM, no JVD
lungs: rales anteriorly
heart: RR, S1 and S2 wnl, no murmurs
abd: +b/s, soft, nt, nd, no masses
extr: right arm: former fistula site, left arm: former fistula
site, no edema
lines: Hickman in right subclav since [**Month (only) 404**], no erythema,
tenderness
Pertinent Results:
Imaging:
[**2135-12-2**] CXR - Fluid overload/CHF with interval worsening. No
pneumonia. Dialysis dialysis.
[**2135-12-2**] CT Head - Limited study. No gross intracranial
hemorrage
[**2135-12-2**] CXR - Left IJ central venous catheter terminates
within the left brachiocephalic vein without associated
pneumothorax. Improving interstitial edema
Cultures:
[**2135-12-2**] Blood - pending
EKG: NSR, rate 110, left atrial abn, lvh with st depressions
v4-v6
Brief Hospital Course:
The patient is a 57 y/o man with history of ESRD on HD, seizure
disorder, chf admitted s/p grand mal seizure and with subsequent
hypoxic respiratory failure.
On arrival in the ED, the patient was intubated for airway
protection. He was transferred to the MICU where he was quickly
weaned and extubated. In the ICU, they felt like he was also
having a subacute CHF exacerbation and he was diuresed 5.5 L
with dilaysis. He is going to have an outpatient ECHO to see if
there is any progression of his CHF. He is also planning to see
a pulmonologist to evaluate for an intrinsic lung disease.
He was seen by neurology who put him on an ativan taper,
increased his lamictal to 200BID and continued his keppra.
Renal was following and restarted his lisinipril at a lower
dose, toprol XL, and nifedipine.
The patient was transferred to the floor where he was observed
overnight and discharged the next morning. He was cleared by PT
prior to discharge.
Medications on Admission:
keppra3 75 [**Hospital1 **]
lamictal 150 am, 200 pm
oxaxepam 10 mg
lisinopril 40 tid
toprol 200
nifedipine xl 120
protonix 40
neurontin 200
nephrocaps, pholo, fosrenol 1000 [**Hospital1 **]
prn ativan, serax, hydroxyzine
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
2. Levetiracetam 250 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
8. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
9. Nifedipine ER 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO once a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Seizure
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
--Please take all medications as prescribed.
--Please go to all follow up appointments.
--Please return to the ED for any SOB, difficulty breathing,
recurrent seizures.
Followup Instructions:
Provider: [**Name Initial (NameIs) 394**]/[**Name8 (MD) 395**] M.D. Date/Time:[**2135-12-8**] 9:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-12-26**] 1:40
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2136-1-26**] 4:00
Please call to schedule a repeat Cardiac ECHO ([**Telephone/Fax (1) 19380**].
You can follow up with the results with Dr. [**Last Name (STitle) 5762**].
Please call an schedule an appointment with Dr. [**Last Name (STitle) 5762**] in [**2-13**]
weeks.([**Telephone/Fax (1) 8417**]
Please call to make an appointment with a Pulmonologist to have
PFT's performed. ([**Telephone/Fax (1) 513**]
|
[
"996.81",
"E849.8",
"403.01",
"070.70",
"428.0",
"E878.0",
"780.39",
"518.81",
"244.9",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7141, 7199
|
4862, 5817
|
326, 333
|
7251, 7260
|
4376, 4839
|
7577, 8351
|
3950, 4014
|
6089, 7118
|
7220, 7230
|
5843, 6066
|
7284, 7554
|
4029, 4357
|
279, 288
|
361, 2629
|
2651, 3741
|
3757, 3934
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,875
| 143,858
|
2548
|
Discharge summary
|
report
|
Admission Date: [**2100-9-20**] Discharge Date: [**2100-10-1**]
Date of Birth: [**2028-4-1**] Sex: F
Service: SURGERY
Allergies:
Percocet / Oxycodone / Lorazepam / Codeine / Amiodarone /
Metoprolol
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Non-healing right toe ulcers.
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Right superficial femoral artery to posterior tibial
artery bypass using left upper arm vein.
2. Angioscopy
History of Present Illness:
This is a 72-year-old female who has undergone
endovascular procedures on both legs and is recently status
post right first and second toe amputations which were found
in the clinic to not be healing well. The patient was
admitted for repeat angiography which revealed no
endovascular options. The patient was then deemed a candidate
for a distal bypass.
Past Medical History:
- CHF (dx in [**2091**], last Echo [**2-14**] with LVEF of 60-65% wit PCWP
of 18, 1+ MR, 2+ TR)
- CAD (s/p triple CABG)
- AS (moderate, 0.8-1.19cm2 valve area)
- Type II DM, now insulin-dependent (last HbA1c was 6.0 in [**9-13**]
per patient)
- CRI secondary to diabetes (recent baseline Cr 3.4-4.6, has
been slowly rising)
-PVD-s/ p angoiplasty of b/l feet in [**2098**]. Toe on left foot
amputated. Has b/l stents in her legs.
last vasc study: right ABI 0.82, Patent left popliteal and
tibial angioplasty site with greater than 50% stenosis at the
proximal tibial peroneal trunk.
- HTN
- Migratory Polyarthritis (dx years ago)
- Hypothyroidism
-Anemia (baseline hct 28-34, nl recent iron studies)
Social History:
No smoking, ETOH, drugs
Lives with husband
Family History:
Father had MI at age 60, Mother had valvular heart disease
Physical Exam:
a/o x 3
nad
laying in bed
cta
[**Last Name (un) 3526**] / [**Last Name (un) 3526**]
abd- benign
Coccyx pressure ulcer: nonstageable, approx. 5 x 4.5 cm, 75%
black soft tissue, 25% yellow. There is a large amount of
serous
yellow drainage with odor. The wound bed is irregular. The
periwound tissue is intact with no erythema, edema, induration,
fluctuance or crepitus. She c/o pain [**5-18**] with palpation of the
site.
Pulses: Fem DP PT [**Name (NI) 12924**]
Rt 2+ - mono 2+
Lt 2+ - mono
surgical inc: C/D/I
Pertinent Results:
[**2100-10-1**] 12:00PM BLOOD
WBC-7.2 RBC-3.23* Hgb-9.8* Hct-31.3* MCV-97 MCH-30.4 MCHC-31.3
RDW-17.8* Plt Ct-214
[**2100-10-1**] 12:00PM BLOOD
Plt Ct-214
[**2100-9-28**] 03:06AM BLOOD
PT-14.4* PTT-33.2 INR(PT)-1.3*
[**2100-10-1**] 04:18AM BLOOD
Glucose-85 UreaN-21* Creat-2.6* Na-133 K-3.5 Cl-97 HCO3-28
AnGap-12
[**2100-10-1**] 04:18AM BLOOD
Calcium-8.8 Phos-2.9 Mg-2.3
Cardiology Report ECHO Study Date of [**2100-9-24**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *4.2 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 70 mm Hg
Aortic Valve - Mean Gradient: 40 mm Hg
Aortic Valve - LVOT Peak Vel: 0.80 m/sec
Aortic Valve - LVOT Diam: 1.9 cm
Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2)
Mitral Valve - Pressure Half Time: 45 ms
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.86
Mitral Valve - E Wave Deceleration Time: 196 msec
TR Gradient (+ RA = PASP): *48 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler. Normal IVC
diameter (1.5-2.5cm) with >50% decrease during respiration
(estimated RAP 5-10 mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderate
regional LV systolic dysfunction. No LV mass/thrombus. TDI E/e'
>15,
suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. No 2D or Doppler evidence of distal arch
coarctation.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Severe
AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild to moderate ([**2-9**]+)
MR. [Due to acoustic shadowing, the severity of MR may be
significantly UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**2-9**]+] TR. Moderate PA systolic hypertension.
Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
moderate regional left ventricular systolic dysfunction with
inferior and infero-lateral akinesis. The remaininf segmetns are
hypokinetic. No masses or thrombi are seen in the left
ventricle. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. There is mild global right
ventricular free wall hypokinesis. The ascending aorta is
mildly dilated. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (area
<0.8cm2). Trace 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.
[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.
Compared to the prior study (reviewed) dated [**2100-6-14**], the overall
LVEF has
decreased. The AS remains severe.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2100-9-24**] 17:10.
Brief Hospital Course:
Mrs. [**Known lastname 12925**],[**Known firstname 539**] C was admitted on [**9-20**] with Non-healing
right toe ulcers. She agreed to have an elective surgery.
Pre-operatively, she was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
Pt with known aortic stenosis, cardiology consulted. cleared for
surgery
Pt also on HD pre-operative, renal was consulted. They followed
the pt closely. Recommendations were adhered to. She recieved
regular HD on her scheduled day.
It was decided that she would undergo a Right superficial
femoral artery to posterior tibial artery bypass using left
upper arm vein.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the CSRU
for further stabilization and monitoring. She remained in the
CSRU vetilated with pressure support for a number of days. While
she was there she developed a pna. This was treated with
Antibiotics.
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. She was discharged home with [**Month/Year (2) 269**]
services.
To note PT recommended rehab / PT refused rehab. Pt did not want
to stay in the hospital for any longer. She and the family
decided that she would be better off at home. Medically pt is
stable for home. But physically she is not.
Medications on Admission:
[**Last Name (un) 1724**]: lopid 600'', levothyroxine 200, diltizem 120'' on non
dialyisis days, neurontin 100, coumadin 1 mg, simvastatin 40
Discharge Medications:
1. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed).
Disp:*10 Pramoxine-Mineral Oil-Zinc (Rectal) 1-12.5 % Ointment*
Refills:*2*
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO non
dialysis days.
11. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
moniter you inr in the usual fashiion.
Discharge Disposition:
Home With Service
Facility:
Partners [**Name (NI) 269**]
Discharge Diagnosis:
Non-healing right toe ulcers.
hyponatremia
post operative confusion
pna
coccyx ulcer
HTN, Chol, DM2 w retinopathy, neuropathy, ESRD (HD MWF thru Rt
IJ Tunnel), anemia of chronic dz, hypothyroid, RA,
CHF(diastolic), severe aortic stenosis
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-13**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2100-11-2**] 11:10
Follow - up with Dr [**Last Name (STitle) **] on [**10-20**] at 1500 hrs.In his [**Location (un) **]
office. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1241**]
Date/Time:[**2100-10-20**] 3:00
Please get your HD on the scheduled days
Completed by:[**2100-10-1**]
|
[
"424.1",
"428.0",
"250.40",
"707.09",
"293.9",
"585.6",
"244.9",
"276.1",
"486",
"428.30",
"440.23",
"707.15",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9550, 9609
|
6385, 8331
|
357, 486
|
9892, 9899
|
2282, 6362
|
12845, 13361
|
1671, 1731
|
8523, 9527
|
9630, 9871
|
8357, 8500
|
9923, 12412
|
12438, 12822
|
1746, 2263
|
288, 319
|
514, 871
|
893, 1594
|
1610, 1655
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,592
| 166,122
|
6844
|
Discharge summary
|
report
|
Admission Date: [**2201-11-7**] Discharge Date: [**2201-11-11**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Bright red [**First Name3 (LF) **] per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yo female w/ PMH HTN, DM2, nephrotic-range proteinuria and an
enlarging renal mass suspicious for malignancy, here with BRBPR
since this morning. Yesterday she felt well, and even this
morning when she woke up at 8am she felt okay. Then at 9am she
had diarrhea mixed with bright [**Last Name (LF) **], [**First Name3 (LF) **] she activated her
lifeline. Denies fevers, chills, abd pain, n/v, dizziness,
lightheadedness, CP/SOB. Has history of lower GI bleed x 2 in
the past, most recently in [**2196**] [**2-11**] diverticulitis, as well as a
duodenal ulcer that was apparently in the setting of NSAID use.
Does take aspirin but no additional anticoagulation.
.
In the ED, initial vitals 98.7 70 166/85 16 100% RA. Exam
notable for [**Month/Day (2) **] and clots on her bed, and large [**Month/Day (2) **] on
rectal. Hct was at 24 from baseline 27 to 30, Cr 2.0 from
baseline 1.4 to 1.7. NG lavage was positive for a small amount
of [**Month/Day (2) **], though without frank bleeding. She got 1 unit PRBC
with a repeat Hct of 24, so she was given another unit PRBC.
Lactate 1.1. A right IJ was placed b/c the patient had difficult
access, started on pantoprazole drip. GI was consulted, who
recommended transfusion and consideration of CT angiogram.
General surgery felt that a diverticular bleed was most likely,
and recommended colonoscopy to find a source. Vitals prior to
transfer 167/67, 73 20 99% RA.
.
On arrival to the ICU, she denies lightheadedness, abdominal
pain or further bowel movements. Repeat NG lavage brought back
only bile.
Past Medical History:
1. Hypothyroidism
2. H/O E. Coli Sepsis ([**4-/2194**])
3. HTN
4. H/O Bronchitis
5. Hepatic Cystadenoma S/P Resection ([**2184**])
6. Cholangitis S/P Stenting
7. PUD (Duodenum)
8. TAH/BSO
9. DJD
10. CAD (2VD s/p DES to D1)
11. Osteoarthritis of the knees
12. Diverticulosis, s/p bleed in [**2196**]
13. Neuropathy
14. Spinal stenosis
15. Nephrotic-grade proteinuria
16. Enlarging renal mass suspected to be malignant
Social History:
Lives at an [**Hospital3 **] facility in [**Location (un) 583**], moved to U.S.
from rural [**Country 651**] 40 years ago. Denies smoking, alcohol, and
drug use. Lives alone in [**Hospital3 4634**] with family near by.
Previously worked in laundering/ironing. Claims real age is 92,
not 90
Family History:
Denies DM, cancer, or HTN.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated. Enlarged, displaced left lobe of
the thyroid.
Lungs: Clear to auscultation except for slight basilar crackles.
CV: Regular rate and rhythm, II/VI systolic ejection murmur
loudest at the RUSB.
Abdomen: Large, well-healed scars. Soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly.
GU: no foley
Ext: warm, well perfused, 2+ pulses. Mild, non-pitting edema.
.
Discharge PEx:
VS: 98.2 154/67 63 18 100%RA
I/O: [**Telephone/Fax (1) 25871**]
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated. Enlarged, displaced left lobe of
the thyroid.
Lungs: Clear to auscultation bilat.
CV: Regular rate and rhythm, II/VI systolic ejection murmur
loudest at the RUSB.
Abdomen: Large, well-healed scars. Soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly.
GU: no foley
Ext: warm, well perfused, 2+ pulses. Mild, non-pitting edema.
Pertinent Results:
Admission labs:
[**2201-11-7**] 11:35AM GLUCOSE-101* UREA N-59* CREAT-2.0* SODIUM-134
POTASSIUM-Labs on admission:
6.4* CHLORIDE-105 TOTAL CO2-21* ANION GAP-14
[**2201-11-7**] 11:35AM ALT(SGPT)-13 AST(SGOT)-36 ALK PHOS-69 TOT
BILI-0.3
[**2201-11-7**] 11:35AM LIPASE-76*
[**2201-11-7**] 11:35AM WBC-9.0 RBC-3.02* HGB-8.1* HCT-24.5* MCV-81*
MCH-26.9* MCHC-33.2 RDW-14.4
[**2201-11-7**] 11:35AM NEUTS-82.1* LYMPHS-10.8* MONOS-2.8 EOS-3.8
BASOS-0.5
[**2201-11-7**] 11:35AM PLT COUNT-280
[**2201-11-7**] 11:35AM PT-12.4 PTT-29.4 INR(PT)-1.0
[**2201-11-7**] 12:25PM GLUCOSE-107* UREA N-62* CREAT-2.1* SODIUM-137
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-14
[**2201-11-7**] 12:56PM LACTATE-1.1
Labs on discharge:
[**2201-11-11**] 06:50AM [**Month/Day/Year 3143**] WBC-7.0 RBC-3.47* Hgb-10.0* Hct-29.4*
MCV-85 MCH-28.8 MCHC-34.1 RDW-14.4 Plt Ct-175
[**2201-11-11**] 12:15AM [**Month/Day/Year 3143**] Hct-28.3*
[**2201-11-11**] 06:50AM [**Month/Day/Year 3143**] Glucose-113* UreaN-35* Creat-2.0* Na-137
K-4.1 Cl-106 HCO3-20* AnGap-15
[**2201-11-11**] 06:50AM [**Month/Day/Year 3143**] Calcium-8.2* Phos-3.6 Mg-1.8
[**2201-11-10**] 06:50AM [**Month/Day/Year 3143**] Osmolal-298
[**2201-11-11**] 05:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2201-11-11**] 05:55AM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2201-11-11**] 05:55AM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-1
[**2201-11-11**] 05:55AM URINE CastHy-4*
[**2201-11-11**] 05:55AM URINE Osmolal-393
[**2201-11-7**] 8:31 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2201-11-10**]**
MRSA SCREEN (Final [**2201-11-10**]): No MRSA isolated.
EKG:
Sinus rhythm. Baseline artifact. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2201-3-7**] the rate has
decreased.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 230 98 384/396 -21 51 70
CXR: There is a new large-bore catheter in the right IJ with tip
in the
right superior vena cava. There is no pneumothorax. Overall
appearance of
the lungs, heart, and mediastinum is similar compared to the
study from
[**2201-3-8**].
Brief Hospital Course:
[**Age over 90 **] yo female w/ PMH HTN, DM2, nephrotic-range proteinuria and an
enlarging renal mass suspicious for malignancy, here with BRBPR
likely [**2-11**] diverticulosis as documented on colonoscopy in [**2196**].
.
# BRBPR. Most likely lower GI source given extensive prior
diverticulosis and negative lavage on repeat. Patient was
admitted to the ICU for hemodynamic monitoring. She was given
pantoprazole 40 PO BID (home dose 20 daily). GI evalauted her
and offered a colonoscopy to look for source of bleed and to
rule out a malignancy. She did not get colonoscopy while in the
MICU because of hemodynamic stability and also she stated that
she would not want to have colonoscopy or any surgery. This was
confirmed multiple times and patient and son both repeated that
she would not want a colonoscopy in the event of a repeat
bleeding episode. She remained hemodynamically stable however
just prior to getting called out of the ICU, she had an
additional bloody bowel movement therefore she was monitored for
an additional day and transfused an additional unit of [**Year (4 digits) **], to
which her crit responded appropriately (baseline and now in high
20s). She did not have any more bowel movements while in the
MICU and diet was advanced to clears. ASA held in event of
recent bleed and can be restarted as needed by PCP should she
continue to be stable, without more bleeding. On the medicine
floor, patient had one more bowel movement with [**Year (4 digits) **] streaks
and roughly 4cc bright red [**Year (4 digits) **]. Hct continued to be stable and
patient had no further bleeding. Patient tolerated regular diet
prior to discharge.
.
# Acute on chronic renal failure: patient has had worsening
renal failure over several months. On admission, in setting of
diarrhea, Cr 2.0 from baseline 1.4 to 1.7. Likely pre-renal vs
worsening chronic renal failure in setting of enlarging left
kidney mass. Cr has remained 1.8-2.0. FeNa 1.3 and proteinuria
has actually improved since hr last admission. Would repeat a
Creatinine in 3 days.
.
# Hypertension. Her antihypertensives were initially held given
BRBPR, however restarted when her pressures were elevated to the
170-180s while in the ICU, patient tolerating well, SBP in 150s
range.
.
# Glaucoma: continue home timolol and latanoprost.
.
# Elevated Lipase: patient without n/v or abdominal pain,
remained persistently elevated while in the ICU.
.
# Code: DNR/DNI, would not want heroic measures or invasive
procedures (discussed with patient and son [**Doctor First Name **]
.
.
Pending tests: none.
.
.
Transitional Issues:
-Patient to have Creatinine checked in 3 days, on [**2201-11-14**].
Medications on Admission:
- amlodipine 10mg daily
- furosemide 20mg PRN leg swelling
- latanoprost 0.005% R eye QHS
- levothyroxine 75mcg daily
- losartan 25mg daily
- metoprolol 50mg [**Hospital1 **]
- omeprazole 20mg QHS
- timolol 0.5% R eye daily
- ursodiol 300mg [**Hospital1 **]
- Aspirin 81mg daily
- Calcium-vitamin D 600mg-200unit
- docusate 100mg PRN
- Senna 8.6mg [**Hospital1 **] PRN
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily): to R eye (OD).
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
Disp:*qs dose* Refills:*0*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime: please discuss
with your doctor at your next visit re: length of course of
PPI/drug holiday.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for constipation.
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for lower extremity edema.
13. Calcium-Vitamin D 600 mg calcium- 400 unit Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
Lower GI bleed, likely [**2-11**] known diverticulosis
acute on chronic renal failure
Secondary:
hypertension
glaucoma
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 **],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted to the hospital for
bleeding through the rectum. Given your clinical presentation
and previous colonoscopy and history of diverticulosis, the most
likely cause of your bleeding is the diverticulosis
(out-pouching/polyps in the colon). We transfused you and your
[**Hospital1 **] counts have been stable. We understand your wish for
repeat colonoscopy refusal and have provided supportive care.
.
We have restarted you on your home medications and have added
one more medication to promote soft and regular stools
(miralax).
.
We wish you a speedy recovery and hope you feel better soon.
Followup Instructions:
You have the following appointments:
Department: [**Hospital3 249**]
When: THURSDAY [**2201-11-19**] at 10:50 AM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: RHEUMATOLOGY
When: TUESDAY [**2202-2-16**] at 2:30 PM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], 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
Department: CARDIAC SERVICES
When: THURSDAY [**2202-5-27**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.9",
"584.9",
"189.0",
"562.12",
"285.1",
"365.9",
"356.9",
"403.90",
"715.36",
"414.01",
"791.0",
"244.9",
"V49.86",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10428, 10511
|
6101, 8680
|
298, 305
|
10699, 10699
|
3847, 3847
|
11609, 13031
|
2663, 2691
|
9190, 10405
|
10532, 10678
|
8796, 9167
|
10882, 11586
|
2706, 3828
|
8701, 8770
|
213, 260
|
4582, 6078
|
333, 1898
|
3863, 3950
|
3964, 4562
|
10714, 10858
|
1920, 2338
|
2354, 2647
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,519
| 116,312
|
26986
|
Discharge summary
|
report
|
Admission Date: [**2184-3-5**] Discharge Date: [**2184-3-9**]
Date of Birth: [**2138-2-26**] Sex: M
Service: SURGERY
Allergies:
Lithium
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
bilateral foot pain and swelling
Major Surgical or Invasive Procedure:
none on this admission
History of Present Illness:
Mr. [**Known lastname 66333**] is a 46-year-old man who claims to have been
trimming tree branches while barefoot and fell out of the tree
into a thorn [**Last Name (un) **]. He sustained multiple abrasions and then went
with a friend to use cocaine, after which he felt bilateral foot
pain and walked to [**Hospital 1474**] Hospital for evaluation. His aunt,
with whom he lives, describes finding him in the garage, wrapped
only in a blanket, near a pile of broken glass. He had scratches
all over his body and complained of foot pain, so she took him
to [**Hospital 1474**] Hospital.
Past Medical History:
bipolar disorder
multiple inpatient psychiatric admissions
self-inflicted stab wound to chest requiring emergent sternotomy
Social History:
+MJ, +cocaine
2 year h/o cigarette smoking
lives with aunt, unemployed
Family History:
NC
Physical Exam:
98.9 95 172/124 20 95%RA
A&Ox3
agitated, uncomfortable
sick-appearing
HEENT: PERRL, EOMI. minor scratches on face
chest: multiple abrasions. CTAB. Midsternal wound healed.
CV RRR
abd: multiple abrasions including on genitals. NTND, soft, +BS
UE: multiple scratches b/l arms concentrated at dorsal/volar
forearms. Erythema b/l hands R>L. SILT M/R/U/A. +TTP throughout
R hand. Necrotic R small digit tip.
LE: multiple scratches b/l LE extending from upper inner thighs
to feet. All leg compartments soft but b/l feet significantly
more tense. Weeping excoriations L foot. Able to express small
amount of pus from excoriation plantar foot. Erythema extending
just distal to knees b/l. 2+ DP pulses. Great and 2nd toes cold
and dusky bilaterally
Pertinent Results:
[**2184-3-5**] 11:45AM WBC-14.3* RBC-4.52* HGB-13.8* HCT-38.3*
MCV-85 MCH-30.5 MCHC-36.0* RDW-13.9
[**2184-3-5**] 11:45AM NEUTS-78.9* BANDS-0 LYMPHS-17.4* MONOS-3.4
EOS-0.1 BASOS-0.2
[**2184-3-5**] 11:45AM PT-13.4* PTT-26.7 INR(PT)-1.1
[**2184-3-5**] 11:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2184-3-5**] 11:45AM GLUCOSE-114* UREA N-51* CREAT-2.1* SODIUM-135
POTASSIUM-5.9* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2184-3-5**] 11:45AM CALCIUM-8.2* PHOSPHATE-4.1 MAGNESIUM-2.4
[**2184-3-5**] 11:45AM CK(CPK)-[**Numeric Identifier 11094**]*
[**2184-3-5**] 02:32PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2184-3-5**] 09:18PM WBC-11.4* RBC-4.37* HGB-13.2* HCT-37.1*
MCV-85 MCH-30.2 MCHC-35.6* RDW-13.8
[**2183-3-9**]: WBC=8.0, Cr=0.9, CK=794
Brief Hospital Course:
Pt was evaluated by multiple services in the ED. He was admitted
to the trauma ICU with a presumed diagnosis of rhabdomyolysis,
acute renal failure, and cellulitis. He was started on
aggressive hydration and his CK and renal assays normalized. ID
was consulted and he received IV Vancomycin/Zosyn for 5 days. He
was maintained on a 1:1 sitter throughout his hospitalization.
He was followed by multiple surgical services but no surgical
intervention was deemed necessary. He was initially somnolent
but his mental status gradually improved. The erythema, edema,
and tenderness to palpation of his extremities gradually
improved with elevation and antibiotics. His lower extremities
were wrapped in compressive dressings with good resolution of
the edema. On hospital day 2 he was improving. He was
transferred to the surgical floor. Psychiatry was consulted
given his extensive psychiatric history. On hospital day 3 he
was advanced to a regular diet and was able to ambulate. Per ID,
a hepatitis panel and HIV test were sent. All hepatitis tests
were negative. The HIV test was still pending at the time of
discharge and will need to be followed as an outpatient. By
hospital day 5 the patient was greatly improved and stable for
discharge. He had stable necrotic tips of the first and 2nd
digits of each foot as well as the small digit of the right hand
on discharge. He will follow-up with Podiatry and Plastic
Surgery for these. Psychiatry agreed that he was stable for
discharge to home. He will follow-up with the TriCity Mental
Health Clinic on Friday. It is possible that he will need
vascular surgery intervention at a later date, although at this
point he has only single digit necrosis on his hands and feet
and bilaterally palpable pulses at his feet. His blood pressure
was also elevated throughout this admission, althought he was
asymptomatic. He was started on Metoprolol 25mg PO BID, which he
will continue at home. He was given the information for the
[**Hospital3 **] internal medicine group and he will
follow-up with his new primary care doctor regarding this issue.
Medications on Admission:
depakote (although blood levels extremely low)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks: take while taking narcotic pain
medication.
Disp:*28 Capsule(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 1 weeks.
Disp:*25 Tablet(s)* Refills:*0*
3. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO at bedtime.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
rhabdomyolysis
acute renal failure
cellulitis
frostbite
bipolar disorder
Discharge Condition:
stable
Discharge Instructions:
You may resume your usual diet and activities as you feel able.
When you are sitting or lying down you should keep your feet
elevated above the level of your heart. You should keep all
scratches and skin breaks clean and dry, do not scratch or pick
at the scabs. You should not drive while taking pain
medications.
Keep all follow-up appointments.
Call your doctor or go to the ER if you experience:
-chest pain or shortness of breath
-fevers or chills
-increased pain, redness, or drainage from your hands or feet
-anything else that concerns you
Followup Instructions:
Follow-up with the TriCity Mental Health clinic on [**2-8**] at 3pm.
Follow-up with Podiatry in 2 weeks. Call ([**Telephone/Fax (1) 21608**] to
schedule your appointment.
Follow-up with Plastic Surgery Hand Clinic in [**2-2**] weeks. Call
[**Telephone/Fax (1) 4652**] to schedule your appointment, appointments are
Tuesdays only.
Follow-up with [**Hospital3 **] to get a new primary care
doctor. They are located in the [**Hospital Ward Name 23**] Atrium ([**Location (un) **]) on
the [**Hospital Ward Name 516**]. Call ([**Telephone/Fax (1) 56960**] to schedule your
appointment. An HIV test was sent on this admission. You can get
the results from your new primary care doctor. In addition, your
blood pressure was elevated throughout this admission. A new
medication, metoprolol, was started which you should take every
day. You should have your blood pressure followed as an
outpatient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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5634, 5640
|
2842, 4932
|
298, 323
|
5757, 5766
|
1974, 2819
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5029, 5611
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5661, 5736
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226, 260
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1101, 1173
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,320
| 108,952
|
4238
|
Discharge summary
|
report
|
Admission Date: [**2108-1-31**] Discharge Date: [**2108-2-13**]
Date of Birth: [**2029-7-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Peanut
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 78 year old man who fell from standing. Per EMS
([**Hospital1 **] Paramedics) he experienced a fall outside of a place of
business (bar), with +LOC, lac to back of head and large
laceration to L side of head, and +ETOH BAL 57. Pt was intubated
and sedated. Upon assessment, no family was available and
patient
was EU Critical [**Doctor First Name 4468**].
Past Medical History:
HTN, stable angina (with rare NTG use), METS > 4 (limited
ability to climb stairs due to OA, not cardiac/respiratory
related), hyperlipidemia, OSA on home CPAP, h/o prostate CA
treated w/ radiation in '[**93**], h/o diverticulitis, OA, spinal
stenosis for which he takes intrathecal injections every 3
months, last being 4 weeks back.
PSH: epigastric hernia repair '[**57**], Moh's for SCC/BCC
Social History:
Lives with his wife and son. Retired from work. Denies
substance abuse
Family History:
Has a twin brother who had prostrate cancer. Mother had breast
cancer in her 90s. Sister had nephrectomy for a renal tumor
Physical Exam:
On Admission: Gen: Intubated/Sedated
Neuro:
No EO to voice or noxious, Pupils are equal and reactive 3-2mm,
+
corneals bilaterally, no blink to threat, BUE localize briskly
to
noxious, BLE withdraw to noxious and move spontaneously. No
commands.
On Discharge:
Gen: Pleasant, cooperative
CV: RR, s1 and S2 normla
Pulm: CTAB
Gi: soft, NT, obese, + BS
Extr: no c/c/e
Muscl: mild R knee effuission
Neuro: AAOx2, follows commands, strength 4+ throughout, Moving
all extremities, reflex 2+ throughout, left facial droop
Pertinent Results:
CT HEAD W/O CONTRAST [**2108-1-31**]
1. Subarachnoid hemorrhage in the basal cisterns, along the left
temporal
lobe, and along the frontal lobes, including in the
interhemispheric fissure. Adjacent subdural hemorrhage along the
left tentorium, and possibly also in the interhemispheric
fissure and along the left temporal lobe.
2. Possible bifrontal hemorragic contusions.
3. Left frontal scalp laceration without evidence of a fracture.
CT ABD & PELVIS WITH CONTRAST [**2108-1-31**]
1. No evidence of traumatic injury to the thorax, abdomen, and
pelvis.
2. Mild subcutaneous soft tissue hematoma overlying the left
greater
trochanter without evidence of fracture.
3. Chronic moderate-to-severe degenerative changes and L4 on L5
anterolisthesis causing moderate narrowing of the spinal canal.
4. Diverticulosis without diverticulitis.
CT HEAD W/O CONTRAST [**2108-2-1**]
1. No significant short-interval changes, with persistent small
focal
hemorrhagic contusions, predominantly in the left frontal lobe,
trace
bilateral subarachnoid hemorrhage and tiny parafalcine subdural
hematoma.
Interval decrease of conspicuity of the left tentorial and left
temporal
subdural hematomas.
2. No developing hydrocephalus. No new foci of intracranial
hemorrhage.
Follow up as clinically indicated.
cxr [**2108-2-4**]
IMPRESSION: AP chest compared to [**1-31**] through 4:
Pulmonary edema has almost resolved since [**2-3**]. Lungs are
grossly clear. Heart size normal. Left subclavian line ends in
the SVC. ET tube in standard placement. Feeding tube passes into
the stomach and out of view. No pneumothorax.
CTA [**2108-2-4**]
IMPRESSION:
1. No evidence of central pulmonary embolism within limitation
of suboptimal bolus. No acute aortic injury.
2. Bibasilar opacifications likely represent atelectasis, left
greater than right. However, underlying infectious process,
especially on the left cannot be completely excluded and should
be considered in the correct clinical setting.
3. Ground-glass opacities predominantly in the apical segment of
the right
lobe and also within the left lobe are again noted, unchanged
from [**2108-1-31**] and may represent edema, hemorrhage, or
infection.
CXR [**2108-2-5**]
FINDINGS: In comparison with the earlier study of this date, the
right
subclavian catheter has been redirected so that the tip lies in
the
mid-to-distal portion of the SVC. Otherwise little change.
[**2108-2-6**] ECHO
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 18435**]Portable TTE
(Complete) Done [**2108-2-6**] at 3:46:36 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
YOUNG, [**Doctor First Name **]
[**Last Name (LF) **], [**First Name3 (LF) **] J.
[**Hospital1 18**] - Division of Neurosurger
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2029-7-20**]
Age (years): 78 M Hgt (in): 72
BP (mm Hg): 142/61 Wgt (lb): 260
HR (bpm): 77 BSA (m2): 2.38 m2
Indication: Endocarditis. Staph bacteremia.
ICD-9 Codes: 424.90, 424.1, 424.0
Test Information
Date/Time: [**2108-2-6**] at 15:46 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**]
[**Last Name (un) 16813**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West
Inpatient Floor
Contrast: None Tech Quality: Suboptimal
Tape #: 2011W000-0:00 Machine: Vivid q-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Left Ventricle - Stroke Volume: 88 ml/beat
Left Ventricle - Cardiac Output: 6.77 L/min
Left Ventricle - Cardiac Index: 2.85 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - LVOT VTI: 28
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 0.73
Mitral Valve - E Wave deceleration time: 235 ms 140-250 ms
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Estimated cardiac index is normal (>=2.5L/min/m2). No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
Technically suboptimal study.
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The estimated cardiac index is normal (>=2.5L/min/m2).
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: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No valvular pathology or pathologic flow
identified.
CLINICAL IMPLICATIONS:
Based on [**2103**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2108-2-6**] 17:20
CXR [**2108-2-6**]
Comparison with the study of [**2-5**], the intestinal tubes have been
removed. There is some increasing prominence of the vascular
structures,
consistent with increasing pulmonary venous pressure. Areas of
opacification at the bases may merely reflect some atelectasis
and vascular structures, though in the appropriate clinical
setting the possibility of supervening pneumonia would have to
be considered, especially at the right.
[**2-12**] Lumbar MRI
1. Transitional anatomy at the lumbosacral junction with
numbering
convention, as detailed above.
2. No finding to specifically suggest discitis, vertebral
osteomyelitis or
epidural abscess/phlegmon in the lumbar spine. However, there is
abnormal
enhancing soft tissue in the caudal aspect of the left neural
foramen at the L4-5 level, adjacent to the exiting left L4 nerve
root, which may relate to the annular tear of the adjacent disc
or to the patient's history of recent "spinal injections"; this
finding should be closely correlated with more detailed
information regarding those procedures.
3. No pathologic focus of radicular or leptomeningeal
enhancement.
4. Severe multilevel, multifactorial degenerative disease,
superimposed on
congenitally abnormal spinal canal geometry, with resultant
severe spinal
canal stenosis at the L4-5 level and multilevel neural foraminal
stenoses, as detailed above.
5. Grossly unremarkable appearance to the imaged paraspinal soft
tissues with no finding to specifically suggest renal, perirenal
or psoas muscle abscess.
LENIs [**2-13**] - negative for DVT
Brief Hospital Course:
This is a 78 year old man s/p unwitnessed fall with + LOC who
was intubated and sedated and sent to ED. On head CT patient was
found to have SAH, SDH, and bifrontal contusions. He was cleared
by trauma for other injuries and transferred to TSICU for Q1H
neuro exams. He remained intubated, but was able to open eye to
voice, localize briskly with BUE, and spontaneous movement in
BLE. Overnight, patient was extubated and on [**2-3**], he was alert
to himself, following simple commands, moving all extremities
antigravity and to commands. His cervical spine was cleared.
Whilst in the ICU he had an epsiode of hypotension and got
re-intubated. His work up yeilded Gm + cocci bacteremia. CTA of
the chast was negative for PE. ECHO was negative for vegitation.
He was started on abx and all of his lines were changed over.
An ID consult was called.
He was extubated a day later and has been doing well. He was
transferred to the stepdown.
He had a speach and swallow evaluation on [**2-6**] which showed signs
of aspiration on thin liquids and mild oral residue with regular
solids. They recommend a PO diet of
nectar-thick liquids and soft solids with 1:1 supervision. They
continued to follow.
A TEE was attempted on [**2-9**], the patient was unable to tolerate
the study w/o additional sedation, hence the study was deffered
and can be performed on an outpaient basis. Recs were left in
paperwork. Patient's diet was advanced and he was transferred to
the floor from the SDU on [**2-10**].
On [**2-11**] the patient remained stable. ID recommended checking
ESR,CRP,WBC since pt had been low grade temps since admission.
They also recommended an MRI L-spine since he had an ESI 2 weeks
prior to initial presentation. He worked with PT and OT.
On [**2-12**] ID recommend a lumbar MRI after it was discovered that
he had a previous steroid injection. MRI shoed no evidence of
discitis or osteomyelitis. Addition, ID recommend a ortho
consult to evaluate right knee effusion as a source of
bacteremia. Ortho evaluated pt on [**2-13**] and recommended that R
knee was not likely to be septic. No further evaluation needed.
On [**2-13**] PICC line was pulled out by patient. PICC line was
reinserted on [**2-13**] with a CXR confirming placement. Now DOD, he
is set for d/c to rehab in stable condition. He will continue
Nafcillin for 4 weeks. He will f/u with ID with Transesophageal
echocardiogram and Dr. [**First Name (STitle) **] in [**2-3**]-6 weeks.
Medications on Admission:
[**Last Name (un) 5487**]
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for PARAPHYMOSIS.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for discomfort.
7. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for discomfort.
8. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. ziprasidone mesylate 20 mg Recon Soln Sig: One (1) Recon Soln
Intramuscular Q6H (every 6 hours) as needed for Agitation.
10. hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP > 140.
11. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours).
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
16. Outpatient Lab Work
ESR, CRP, CBC with diff qweekly - Monday to be faxed to [**Hospital **]
clinic at [**Hospital1 18**] [**Telephone/Fax (1) 1419**]. Attention: Dr. [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) 4427**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
BIFRONTAL CONTUSIONS
ACUTE DELIRIUM
SUBARACHNOID HEMORRHAGE
SUBDURAL HEMATOMA
FACIAL LACERATION
BACTEREMIA
RESPIRATORY FAILURE
R knee pain with mod effusion
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:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2108-2-13**]
|
[
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"401.9",
"305.00",
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.93",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14590, 14667
|
10319, 12792
|
275, 282
|
14868, 14868
|
1876, 8275
|
15998, 16360
|
1202, 1326
|
12868, 14567
|
14688, 14847
|
12818, 12845
|
15051, 15975
|
1341, 1341
|
8298, 10296
|
1602, 1857
|
230, 237
|
310, 679
|
1355, 1588
|
14883, 15027
|
701, 1097
|
1114, 1186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,478
| 163,368
|
31138
|
Discharge summary
|
report
|
Admission Date: [**2186-1-19**] Discharge Date: [**2186-2-13**]
Date of Birth: [**2160-9-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Hyperkalemia/Hypotension/Decompensated, End-Stage Heart Failure
Major Surgical or Invasive Procedure:
ICD Placement
Central Line placement
History of Present Illness:
Mr. [**Known lastname **] is a 25-year-old male with a past medical history of
dilated cardiomyopathy (EF of 25%), hypothyroidism (secondary to
thyroid ablation in setting of Grave's disease), and morbid
obesity who is admitted from [**Hospital1 18**] ED with acute renal failure
and hyperkalemia. One week prior to admission, Mr. [**Known lastname **] was
started on Torsemide 100mg QD by his outpatient cardiologist.
Mr. [**Known lastname **] reports feeling nauseated since with dry heaves and poor
PO intake; he continued to take his diuretics during this time.
He has "ripping" abdoming pain every time he dry heaves. Mr. [**Known lastname **]
also endorses some bright red blood in his stools for the past 2
days. He denies vomiting, diarrhea, shortness of breath, fevers,
chills, visual changes, or any other signs of acute illness.
Patient denies any recent travel, no new exposures, and says
that he has been having relatively normal urine output for the
last few days.
.
Upon arrival to ED, initial vitals were: 96.3 88 90/49 18 SP02
100% on RA. Creatinine was 8.2 up from a baseline of 1.1.
Potassium was 7.0 (eventually rose to 7.4) and white count was
16.4. FeUrea 18%. Patient received calcium, 10 units of
regular insulin, an amp of D50, and 40mg IV PPI. An EKG showed
QRS widening and PR prolongation. CXR was without infiltrate
and bedside ultrasound was negative for pericardial effusion. A
non-contrast CT of the abdomen showed no evidence of acute
intra-abdominal process. Upon arrival to MICU, vitals were: 84,
80/35, 22, 100% on RA.
Past Medical History:
1. [**Doctor Last Name 933**] disease, s/p 16 mCi of radioactive iodine in [**1-/2183**]
2. Dilated cardiomyopathy, presumed etiology: tachycardia or
atrial fibrillation
3. Asthma
4. Left sided SVC
Social History:
Patient lives with his parents and brother in [**Location (un) 686**]. He
graduated high school and is taking courses at community
college. He denies ETOH, tobacco, or IV drug use. Mr. [**Known lastname **] walks
for exercise but becomes tired very easily. He spends his days
"relaxing," watching TV, and playing on the computer. His
father is Vietnamese and his mother is [**Name (NI) 73508**].
Family History:
Aunt and maternal grandmother with hyperthyroidism. Brother
with asthma. Paternal grandmother with diabetes
Physical Exam:
Physical exam on admission:
VS: Afebrile, 88, 93/32, SP02 100% on RA
GEN: Pleasant, obese, NAD
HEENT: PERRL, EOMI, anicteric, mucous membranes slightly dry,
MMM, no supraclavicular or cervical lymphadenopathy, JVD
difficult to assess
RESP: CTA b/l, though difficult to appreciate with body habitus
CV: RR, S1 and S2 wnl, no m/r/g
ABD: +BS, obese, non-tender, non-distended
EXT: Enlarged ankles bilaterally, but no pitting
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3
RECTAL: + bright blood in rectal vault
.
Physical exam after passing away:
Pupils were dilated and unreactive to light. NO corneal
reflexes.
No breath sounds.
No pulses.
No heart sounds.
No response to sternal rub and painful stimuli.
Pertinent Results:
Admission labs:
[**2186-1-19**] 09:15AM PLT COUNT-392
[**2186-1-19**] 09:15AM NEUTS-85.1* LYMPHS-11.4* MONOS-2.4 EOS-0.6
BASOS-0.6
[**2186-1-19**] 09:15AM WBC-16.4* RBC-3.79* HGB-11.2* HCT-33.1*
MCV-87 MCH-29.5 MCHC-33.7 RDW-14.8
[**2186-1-19**] 09:15AM DIGOXIN-2.6*
[**2186-1-19**] 09:15AM cTropnT-0.29*
[**2186-1-19**] 09:15AM LIPASE-118*
[**2186-1-19**] 09:15AM ALT(SGPT)-57* AST(SGOT)-68* CK(CPK)-163 ALK
PHOS-110 TOT BILI-0.6
[**2186-1-19**] 09:15AM estGFR-Using this
[**2186-1-19**] 09:15AM GLUCOSE-148* UREA N-116* CREAT-8.2*#
SODIUM-135 POTASSIUM-7.0* CHLORIDE-98 TOTAL CO2-18* ANION
GAP-26*
[**2186-1-19**] 11:00AM LACTATE-2.2* K+-7.4*
[**2186-1-19**] 11:15AM URINE EOS-NEGATIVE
[**2186-1-19**] 11:15AM URINE MUCOUS-RARE
[**2186-1-19**] 11:15AM URINE HYALINE-4*
[**2186-1-19**] 11:15AM URINE RBC-5* WBC-13* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-1
[**2186-1-19**] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2186-1-19**] 11:15AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2186-1-19**] 11:15AM URINE GR HOLD-HOLD
[**2186-1-19**] 11:15AM URINE HOURS-RANDOM UREA N-473 CREAT-180
SODIUM-30 POTASSIUM-62 CHLORIDE-22
[**2186-1-19**] 11:51AM K+-7.3*
[**2186-1-19**] 02:06PM PLT COUNT-363
[**2186-1-19**] 02:06PM WBC-15.3* RBC-3.34* HGB-9.9* HCT-29.6* MCV-89
MCH-29.7 MCHC-33.5 RDW-14.8
[**2186-1-19**] 02:06PM CALCIUM-7.6* PHOSPHATE-7.1*# MAGNESIUM-2.1
[**2186-1-19**] 02:06PM CK-MB-4
[**2186-1-19**] 02:06PM CK(CPK)-147
[**2186-1-19**] 06:34PM FREE T4-1.3
[**2186-1-19**] 06:34PM TSH-5.9*
[**2186-1-19**] 06:34PM CALCIUM-7.2* PHOSPHATE-7.1* MAGNESIUM-1.9
[**2186-1-19**] 06:34PM GLUCOSE-130* UREA N-105* CREAT-7.9*
SODIUM-137 POTASSIUM-5.8* CHLORIDE-103 TOTAL CO2-19* ANION
GAP-21*
.
Imaging:
TTE [**1-23**]:
Very poor image quality. The left atrium is moderately dilated.
LV systolic function appears severely depressed. The diameters
of aorta at the sinus, ascending and arch levels are normal.
There is no aortic valve stenosis. No aortic regurgitation is
seen. No mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2185-4-20**], the LV may be more dilated. If
indicated, a cardiac MRI or nuclear gated blood pool scan (MUGA)
may be better to assess LV size and systolic function.
CT abd/pelvis [**1-22**]:
IMPRESSION:
1. No acute intra-abdominal process; specifically no evidence of
obstruction.
2. Fatty liver.
3. No colonic wall thickening to suggest colitis or toxic
megacolon.
LLE LENI [**1-21**]:
IMPRESSION: No evidence of DVT in the left lower extremity.
CT abd/pelvis [**1-19**]:
IMPRESSION:
1. No evidence for colitis or other acute intra-abdominal
process.
2. Fatty liver.
.
ECHO [**1-23**]:
Very poor image quality. The left atrium is moderately dilated.
LV systolic function appears severely depressed. The diameters
of aorta at the sinus, ascending and arch levels are normal.
There is no aortic valve stenosis. No aortic regurgitation is
seen. No mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2185-4-20**], the LV may be more dilated. If
indicated, a cardiac MRI or nuclear gated blood pool scan (MUGA)
may be better to assess LV size and systolic function.
.
Upper extremity ultrasound [**2-1**]:
Normal study, specifically with no right upper extremity deep
venous thrombosis.
.
CT Abdomen/Pelvis [**1-30**]:
1. No evidence of colitis or toxic [**Last Name (un) 2432**]-colon. No other acute
abdominal
pathology.
2. Fatty liver.
3. Small amount of ascites, new since the prior study.
.
CXR [**2-8**]:
1. The left PM/ICD lead runs down the accessory left SVC,
through the
coronary sinus, and ends in the left ventricle.
2. Unchanged moderate cardiomegaly.
3. Increased vascular distension with possible marginal edema.
Brief Hospital Course:
Mr [**Known lastname **] is a 25-year-old gentleman with a past medical history of
end-stage heart failure, DCM (EF of 25%), hypothyroidism, and
obesity who is admitted to MICU with acute renal failure,
hyperkalemia, hypotension C.diff infection, with course
complicated by decompensated end-stage heart failure s/p
admission to the CCU for IV milrinone therapy.
.
Patient expired at 1200 on [**2186-2-13**].
.
# Dilated Cardiomyopathy/End-stage CHF: Patient has a history
of non-ischemic dilated cardiomyopathy and end-stage heart
failure. He was rejected by the transplant program at [**Hospital1 3278**] due
to BMI > 40. Initially, outpatient regimen of lisinopril,
spironolactone, and digoxin were held due to hypotension and
renal failure while on pressors in the MICU. Hypotension was
thought to be secondary to dehydration and infection from C.
diff. He was able to be weaned off pressors after 2 days in the
MICU. When he was hemodynamically stable, the medication regimen
was restarted; however, the patient then began experiencing
refractory hypotension and worsening renal function, along with
weight gain and signs of severe volume overload. Repeat TTE
which showed EF was 15-20%. He was started on a lasix drip and
did not respond. Due to his end-stage heart failure, he was
transferred to the CCU for milrinone drip initiation. He was
started on .25 mcg/kg/min in addition to lasix drip and
pressures initially required support with phenylephrine. He
began to put out net negative 3-4 L per day in urine and
symptoms improved. The milrinone drip was eventually titrated
up to .75, and both the lasix drip and pressors were weaned. An
ICD was placed in the EP lab to prevent an fatal arrythmias and
patient tolerated the procedure, requiring a short course of neo
post-op. He was evaluated by the transplant team at [**Hospital1 756**],
who stated that he would be a transplant candidate if he loses
enough weight for his BMI to be < 40. See below for nutritional
recommendations. After ICD placement, patient again developed
worsening renal function, weight gain, and hypotension. He was
transferred back to CCU, was started on pressors, and had to be
intubated due to pulmonary edema. CVVH was started. After
discussion with the family, decision was made to make patient
comfort measures only (CMO). Patient was weaned off CVVH,
pressors were stopped, patient was extubated, and shortly
afterwards had PEA. Patient passed away at 12:00 pm on [**2186-2-13**].
.
# Nutrition: Patient must lose roughly 100 pounds over the next
4-6 months to be considered for transplant as outlined above.
Nutrition was consulted, and recommended Optisource shake,
along with fluid and calorie restriction. Patient can have
vegetables such as broccoli and spinach.
.
# ACUTE RENAL FAILURE/HYPERKALEMIA: Patient's baseline
creatinine 1.2. Upon admission, Cr was 8.2. Acute elevation in
Cr secondary to pre-renal etiologies/ATN from intial
presentation of hypotension. As patient was started on
milrinone, he began to put out large amounts of urine, Cr
initially normalized. However, after ICD placement, urine output
again decreased with increase of Cr (see above, end-stage CHF).
Lasix drip and milrinone was ineffective in increasing urine
function after transfer back to CCU. CVVH was initiated and
stopped after family decided to withdraw care.
.
# C. DIFF INFECTION: Patient found to be C.diff toxin positive
and was initially treated with po flagyl, however his abdominal
pain remained. He underwent a CT abd/pelvis to evaluate for
toxic megacolon which showed no acute intrabdominal issue. He
was also changed to po vanc and flagyl and completed [**11-3**] day
course.
.
# BRBPR: Patient complains of BRBPR while stooling
intermittently. His bleeding is similar to bleeding he's had
from hemorrhoids in the past. Patient complains of
constipation. No lightheadedness or dizziness. GI was
consulted in the ED who recommended trending hematocrits and
pantoprazole 40mg IV. He was placed on stool softeners (which
were held when he developed diarrhea). His Hct has been stable.
.
# HYPOTHYROIDISM: He was continued on levothyroxine TSH was
checked and was 5.9 with a free T4 of 1.3 (normal).
Medications on Admission:
digoxin 250 mcg Tablet daily
metoprolol succinate 300 mg daily
omeprazole 20 mg Capsule daily
levothyroxine 274 mcg Tablet daily
lisinopril 20 mg daily
spironolactone 25 mg Tablet daily
aspirin 81 mg Tablet daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cariomyopathy
Chronic systolic heart failure
Acute on chronic kidney failure
Hypothyroidism
Hyperkalemia
Clostridium difficile colitis
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
Completed by:[**2186-2-13**]
|
[
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"995.93",
"V85.43",
"428.0",
"455.8",
"584.5",
"585.9",
"244.1",
"276.7",
"E942.1",
"276.2",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.94",
"96.71",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12157, 12166
|
7642, 11865
|
369, 407
|
12345, 12354
|
3514, 3514
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2657, 2767
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12128, 12134
|
12187, 12324
|
11891, 12105
|
12378, 12384
|
2782, 2796
|
265, 331
|
435, 2001
|
3530, 7619
|
2810, 3495
|
2023, 2222
|
2238, 2641
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,073
| 111,736
|
46109
|
Discharge summary
|
report
|
Admission Date: [**2168-9-30**] Discharge Date: [**2168-10-11**]
Date of Birth: [**2104-6-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
PEG
central venous catheterization, removed [**2168-10-11**]
History of Present Illness:
The pt is a 64 year-old man with PMHx of IDDM, Multiple
Sclerosis
and longterm tobacco abuse who presents with slurred speech and
worsened R-sided weakness, and was found at an OSH to have a
2.5cm pontine hemorrhage.
The hx was obtained mostly from pt's wife. She reports that at
baseline the patient has weakness from his MS of his R leg, most
notable for a R foot drop as well as weakness of his R hand, of
which he can only use his 1st digit and thumb, and the other are
"always closed in a fist". He uses a walker to get around.
However, this morning he woke up and was slurring his speech,
which is unusual for him unless his blood sugar is too low. She
checked his blood sugar and it was 30. She gave him glucose and
[**Location (un) 2452**] juice and unlike other times it has been too low, his
slurred speech didn't improve. In addition, she noticed that
his
R face was drooping and his R eye was at first "too open" and
then the eyelid was droopy. She called 911 and he was taken to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], where a CT scan showed a 2.5cm pontine hemorrhage.
He was then sent to us for further evaluation. Of note, he was
note noted to be hypertensive at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], with BP max
recorded in the 150's. He does not have hypertension at
baseline.
When he arrived in our ED, his BP was in the 130's and he was
taken to a repeat CT scan, which showed an essentially unchanged
hemorrhage in the pons. He was seen by neurosurgery who felt
that the bleed was too deep to intervene surgically at this
point. His initial neurological exam showed essentially full
eye
movements and then a repeat exam 1 hour later showed inability
to
look horizontally and difficulty with downward gaze L > R.
Therefore, given the changing exam and the location of his bleed
he was admitted to the ICU for closer monitoring.
On neuro ROS, the pt reports a mild R sided HA, [**3-26**], as well as
worsened right sided weakness, but denies loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies new difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- IDDM
- Multiple Sclerosis follow by a [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98108**] (sp?)
Social History:
lives at home with his wife. Denies EtOH or illicits,
has smoked for "many years", is a retired respiratory therapist
Family History:
no hx of strokes or seizures
Physical Exam:
Vitals: T: 96.8 P: 62 R: 18 BP: 138/64 SaO2: 100% on 2L NC
General: Awake, cooperative, NAD.
HEENT: dry MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: multiple small areas of skin breakdown on legs bilaterally
Neurologic:
-Mental Status: Alert, oriented x 2 (said it was Wednseday and
didn't know the date), but could get the year, location and
current president. Able to relate history without difficulty
except for significant dysarthria. Attentive, able to name DOW
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Unable to read without glasses. Speech was
significantly dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm and brisk. VFF to confrontation.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages. R eye with ptosis.
III, IV, VI: EOMI without nystagmus on initial exam with
inability to bury the sclera bilaterally, but on repeated exam
pt
unable to look laterally to the left or right and when looking
down the L eye had upward beating nystagmus and both eyes had
difficulty with down gaze with skew deviation.
V: Facial sensation intact to light touch.
VII: R facial droop as well as R ptosis
VIII: Hearing intact to finger-rub in L, but decreased in R
(chronic hearing loss).
IX, X: Palate sluggish to elevate, no gag obtained on tongue
depressor testing.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protruded intially to the L, then on repeat testing
was midline.
-Motor: Decreased bulk in LE's bilaterally. No pronator drift on
L, but is unable to life R arm high enough to adequately test.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5- 5 5- 5- 5 4+ 5-
R 3 4 4 4 5 2 1 3 4+ 3 1 1 0 1
-Sensory: intact to light touch and pinprick throughout. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 1
Plantar response was extensor R > L bilaterally.
-Coordination: Only able to test LUE as RUE is too weak, but no
dysmetria on the R FNF test.
-Gait: Deferred as pt requires walker at baseline and currently
weaker than baseline in RLE.
DISCHARGE EXAM
Unchanged from above.
Pertinent Results:
[**2168-9-30**] 11:20AM BLOOD PT-11.6 PTT-33.6 INR(PT)-1.1
[**2168-9-30**] 11:20AM BLOOD Glucose-166* UreaN-28* Creat-0.9 Na-136
K-4.4 Cl-99 HCO3-27 AnGap-14
[**2168-10-11**] 04:53AM BLOOD Glucose-186* UreaN-18 Creat-0.6 Na-140
K-4.3 Cl-103 HCO3-35* AnGap-6*
[**2168-10-1**] 02:36AM BLOOD ALT-15 AST-27 LD(LDH)-205 CK(CPK)-342*
AlkPhos-89 TotBili-0.5
[**2168-10-6**] 09:07AM BLOOD CK(CPK)-222
[**2168-10-1**] 02:36AM BLOOD CK-MB-5 cTropnT-<0.01
[**2168-10-11**] 04:53AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5*
Mg-1.7
[**2168-10-1**] 02:36AM BLOOD %HbA1c-8.4* eAG-194*
[**2168-10-1**] 02:36AM BLOOD Triglyc-75 HDL-69 CHOL/HD-2.3 LDLcalc-74
[**2168-10-1**] 02:36AM BLOOD TSH-0.62
[**2168-10-1**] 02:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
The pt is a 64 year-old man with PMHx of IDDM, Multiple
Sclerosis
with baseline right side weakness and long term tobacco abuse
who
presents with slurred speech and worsened R-sided weakness, and
was found to have a 2.5cm pontine hemorrhage in CT , confirmed
with MRI. At the time of admission his exam was notable for
dysarthric speech, R ptosis and facial droop and R-sided
weakness
worse than his reported baseline. His pontine hemorrhage is in a
concerning location, but the etiology is not yet clear. His
hemorrhage is a typically hypertensive location, yet the patient
doesn't have HTN nor was he reported as hypertensive at the OSH.
He was admitted to the ICU for further monitoring.
1. Hemorrhagic lesion in L pontine: in serial CT hemorrhage size
remained stable, he recieved hypertonic saline for 24 hours. A
follow-up MRI was scheduled for outpatient.
2. ID: His urine analysis was positive for WBC and Bacteria, he
recieved 1 week of IV ceftriaxone. He developed fever and
leukocytosis again and as CXR was positive for infiltration, he
was started on cefepime, flagyl and vancomycin x 9 days
3. Feeding: he had swallowing evaluation, which showed impaired
swallowing, PEG tube placed for feeding
4. MS: Alert, oriented x3
5. Cardiovascular: TTE showed elongated left atrium but no focal
wall motion abnormalities, LVEV> 55%. He developed 2 episodes of
atrial fibrillation and recieved esmolol drip on the first
episode and diltiazem drip at the second episode. He was
subsequently started on labetalol. He was hypertensive prior to
discharge and his lisinopril was increased to 5mg.
Medications on Admission:
humalog ISS
- lantus 27 units QAM
- oxybutynin chloride ER 10mg QD
- zoloft 50mg QAM
- gabapentin 600mg [**Hospital1 **]
- tizanidine 4mg QAM and 8mg QHS
- ampyra 10mg [**Hospital1 **]
- copaxone 20mg SC QD
- ASA 81mg QD
- lisinopril 2.5mg QD
- MVI QD
- B12 QD
- vitamin D QD
Discharge Medications:
1. Copaxone *NF* (glatiramer) 20 mg Subcutaneous daily
2. Oxybutynin 10 mg PO TID
XR form
3. Ampyra *NF* (dalfampridine) 10 mg Oral [**Hospital1 **]
4. Cyanocobalamin 100 mcg PO DAILY
5. Gabapentin 600 mg PO BID
6. lantus 27 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
7. Labetalol 200 mg PO BID
HOLD FOR SBP LESS THAN 130 AND HR LESS THAN 50
8. Lisinopril 5 mg PO DAILY
Hold for sbp < 100
9. Multivitamins 1 TAB PO DAILY
10. Nicotine Patch 14 mg TD DAILY
11. Sertraline 50 mg PO DAILY
12. Tizanidine 4 mg PO QAM
13. Tizanidine 8 mg PO QPM
14. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
primary: left pontine hemorrhage, pneumonia (resolved)
secondary: multiple sclerosis, hypertension, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 48612**],
You were admitted to the hospital with speech difficulties and
worsening of your right sided weakness. These were found to be
due to a stroke, a bleed in the brain, in an area called the
pons. The reason for this stroke is not yet clear.
We have made the following changes to your medications:
1. We increased your lisinopril to 5mg daily.
2. We started a medication called labetalol for atrial
fibrillation.
3. We have stopped your aspirin.
Please continue your tizanidine, gabapentin, and labetalol at
your regular doses.
You have an MRI that is tentatively scheduled for [**2168-12-2**] prior
to your appointment with Dr. [**First Name (STitle) **] to evaluate the area of the
bleed. Radiology will contact you with the specific time and
date.
It was a pleasure caring for you.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2168-12-13**] 11:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2168-10-11**]
|
[
"276.3",
"E879.6",
"784.51",
"599.0",
"599.71",
"401.9",
"431",
"V58.67",
"427.31",
"340",
"374.30",
"867.0",
"736.79",
"507.0",
"781.94",
"728.89",
"V49.86",
"348.30",
"427.89",
"348.5",
"305.1",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"38.97",
"96.6",
"45.13",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9729, 9803
|
7187, 8790
|
322, 385
|
9967, 9967
|
6385, 7164
|
10948, 11233
|
3438, 3468
|
9117, 9706
|
9824, 9946
|
8816, 9094
|
10102, 10405
|
4609, 6366
|
3483, 3971
|
10434, 10925
|
267, 284
|
413, 3111
|
9982, 10078
|
3133, 3286
|
3302, 3422
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,246
| 138,091
|
18013+18014+56907
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2130-5-11**] Discharge Date: [**2130-5-12**]
Date of Birth: [**2084-10-31**] Sex: M
Service:
ADMISSION DIAGNOSIS:
Pancreatic mass and chronic pancreatitis.
HISTORY OF PRESENT ILLNESS: The patient was admitted [**5-11**]
for an endoscopic retrograde cholangiopancreatography. The
patient is a 45 year-old gentleman with a history of chronic
pancreatitis due to chronic and current heavy alcohol
consumption. He also has new onset diabetes. He previously
had a CAT scan showing abnormal pancreatic head enlargement,
calcifications and biliary dilation in addition to
cholestatic liver function tests. The patient underwent
endoscopic retrograde cholangiopancreatography on [**5-11**].
This showed chronic calcific pancreatitis, multiple stones in
the main pancreatic duct, a biliary stricture compatible with
chronic pancreatitis versus pancreatic cancer. The patient
underwent successful biliary sphincterotomy. Plastic stent
was successfully placed in the common bile duct. The patient
was then admitted to the Medicine Service overnight for
observation. At the time of admission the patient denied
abdominal pain, nausea, vomiting. He stated he had chronic
diarrhea that has gone on for months. He denies melena or
bright red blood per rectum. He denied chest pain or
shortness of breath. The patient states he currently drinks
at least two beers per night. His last drink was the day
prior to admission. The patient rarely goes a day without
drinking.
PAST MEDICAL HISTORY:
1. Chronic pancreatitis with calcified pancrease.
2. Diabetes due to pancreatic insufficiency, resent onset.
3. Chronic alcohol abuse with a history of DTs.
4. Possible benign prostatic hypertrophy.
5. Pancreatic mass and biliary dilation.
6. Depression.
7. Anxiety.
MEDICATIONS AT HOME:
1. Actos 15 mg po q.d., although the patient stopped taking
this a few weeks prior to admission against the advise of his
physician.
2. Protonix 40 mg po q day.
3. Viokase 60/16/60 three tables each meal.
4. Wellbutrin SR 150 mg po b.i.d.
5. Zoloft 200 mg po q.d.
6. Insulin NPH 10 units subq in the morning.
7. Trazodone 400 mg po q.h.s.
8. Motrin prn.
ALLERGIES: Ativan causes severe agitation.
SOCIAL HISTORY: The patient lives at home. He is disabled.
He has been smoking two packs per day for twenty years. The
patient drinks at least two beers per day.
FAMILY HISTORY: Mother had abdominal aneurysm.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.9. Blood
pressure 130/88. Heart rate 64. Respirations 16. Sating
96% on room air. A finger stick was 314. The patient was
thin and in no acute distress. He was not jaundice. There
was no scleral icterus. Pupils are equal, round and reactive
to light bilaterally. Mucous membranes are moist. Heart
sounds were regular. There was no murmurs, rubs or gallops.
Chest is clear to auscultation bilaterally. Bowel sounds are
present. The abdomen was soft and mildly tender in the
epigastric area as well as the right upper quadrant. There
were no peritoneal signs. There was no peripheral edema.
The patient was alert and oriented times three with no focal
neurological deficits.
LABORATORY: White blood cell count 8.0, hematocrit 39.8,
platelets 299, INR 1.0, PT 12.6, PTT 31.0, ALT 191, AST 123,
alkaline phosphatase [**10-28**], amylase 79, total bilirubin 0.5,
lipase 56.
The patient underwent an endoscopic retrograde
cholangiopancreatography, which showed chronic calcific
pancreatitis, multiple stones in the main pancreatic duct,
biliary stricture consistent with chronic pancreatitis versus
pancreatic cancer. Cytology was sent. The patient underwent
sphincterotomy and plastic stenting in the common bile duct.
The gallbladder does not fill with contrast. CT of the
abdomen from [**2130-4-8**] showed large heterogenous ill defined
mass in the pancreatic head displacing the adjacent duodenum
anteriorly and laterally and abutting approximately 50% of
the SMV circumference, which was slightly distorted by the
mass. The mass was poorly marginated. The mass caused some
obstruction of the biliary system with intrahepatic ductal
dilation. As well there was atrophy and calcified neck at
body and tail of the pancrease with calcifications in the
head consistent with chronic pancreatitis.
HOSPITAL COURSE: The patient was admitted to the Acove
Medicine Service.
1. Chronic pancreatitis and pancreatic mass: The patient
underwent an endoscopic retrograde cholangiopancreatography
on the day of admission. He was then kept NPO overnight and
monitored. The next day the patient felt well. He was able
to tolerate po.
2. Diabetes: The patient normally takes Actos and 10 units
of NPH in the morning. While he was NPO he was placed on a
regular insulin sliding scale. On the night of the admission
the patient received 8 units of regular insulin for finger
stick of 314. The patient then became hypoglycemic with
finger stick blood sugar of 19. Over the course of
approximately two hours the patient required 4 amps of D50 as
well as D5W at 200 cc an hour to maintain a blood sugar of
greater then 60. When his finger stick was 19 the patient
felt diaphoretic and was slightly confused. The patient's
NPH insulin was held the next morning. The patient was
allowed to resume po intake. The patient's finger sticks
then improved to the 200 to 300 range. The patient will
resume his outpatient diabetes regimen once he is discharged.
3. Alcohol abuse: The patient has a history of alcohol
withdraw. He stated that he never goes a day without
drinking. The patient has previously had bad reactions with
Ativan. He was therefore given a one time dose of Valium 5
mg on the night of admission. A CIWA scale was checked q 2
hours. The patient did not require any further
benzodiazepines and showed no signs of withdraw.
4. Depression/anxiety: The patient was continued on his
outpatient psychiatric medications.
DISCHARGE DIAGNOSES:
1. Chronic pancreatitis.
2. Pancreatic mass.
3. Status post endoscopic retrograde
cholangiopancreatography with cytology pending.
4. Diabetes.
5. Hypoglycemia.
6. Alcohol abuse.
7. Possible benign prostatic hypertrophy.
8. Depression.
9. Anxiety.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q.d.
2. Viokase 60/16/60 three tablets with each meal.
3. Wellbutrin SR 150 mg po b.i.d.
4. Trazodone 200 mg po q.h.s.
5. Ibuprofen prn.
6. Actos 15 mg po q.d.
7. NPH insulin 10 minutes subq in the a.m.
DISCHARGE FOLLOW UP: The patient will continue to be
followed by the GI Service. Cytology from biopsy taken
during the endoscopic retrograde cholangiopancreatography is
pending at this time.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2130-5-12**] 10:50
T: [**2130-5-15**] 07:04
JOB#: [**Job Number 49856**]
Admission Date: [**2130-5-11**] Discharge Date: [**2130-5-12**]
Date of Birth: [**2084-10-31**] Sex: M
Service: ACOVE
ADMISSION DIAGNOSIS:
Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old
gentleman who had been discharged approximately ten hours
prior to admission after an episodes of chronic pancreatitis.
He underwent endoscopic retrograde cholangiopancreatography
and had stenting of his bile duct as well as biopsies taken
of a possible pancreatic head mass. The patient returned
home where he consumed a large meal and two beers. He then
developed severe abdominal pain. He describes the pain as
epigastric and periumbilical and 10 out of 10. He
experienced some nausea and vomited once. He denies any
blood in the emesis. He denies chest pain, shortness of
breath, fevers, chills, melena, hematochezia, headache,
weakness, paresthesias, change in urinary or bowel habits.
PAST MEDICAL HISTORY:
1. Chronic pancreatitis secondary to alcohol abuse.
2. Diabetes.
3. Depression.
4. Status post correction for duplicated renal collecting
system.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg po q.d.
2. Viokase three tablets t.i.d.
3. Wellbutrin 150 mg po b.i.d.
4. Zoloft 100 mg po q.d.
5. Trazodone 200 mg po q.h.s.
6. NPH insulin subq in the morning.
7. Actos 15 mg po q.d.
SOCIAL HISTORY: The patient smokes two packs per day for
several years. He drinks at least two beers per day. He
rarely goes a day without drinking. He denies intravenous
drug use.
FAMILY HISTORY: Mother had a cerebral aneurysm.
PHYSICAL EXAMINATION ON ADMISSION: The temperature is 97.2.
Blood pressure 156/102. Heart rate 67. Respiratory rate 15.
Sating 100% on room air. The patient is lying in bed in
pain. The head is atraumatic. Pupils are equal, round and
reactive to light bilaterally. Extraocular movements intact.
Neck is supple. There is no lymphadenopathy. The heart has
a regular rate and rhythm. S1 and S2 are normal. There are
no murmurs, rubs or gallops. Chest is clear to auscultation
bilaterally. The abdomen is soft with right periumbilical
tenderness. There is voluntary guarding and rebound. There
is no clubbing, cyanosis or edema in the periphery. The
patient is alert and oriented times three with nothing focal
on neurological examination.
LABORATORY: White blood cell count 18.7, hematocrit 38.2,
platelets 239, sodium 134, potassium 3.6, chloride 99, bicarb
22, BUN 8, creatinine 0.7, glucose 147, ALT 93, AST 20,
amylase 156, alkaline phosphatase 707, LDH 176, lipase 199,
total bilirubin 0.3. The INR is 0.9, PT 11.9, PTT 28.3.
Blood cultures were drawn in the Emergency Department.
CT of the abdomen and pelvis showed a hemorrhage in toward
the pancreatic head and pneumophila.
HOSPITAL COURSE: 1. The patient was admitted to the Acove
Medicine Service. He was evaluated by interventional
radiology and had embolization of his gastroduodenal artery
to control the hemorrhage into his pancreatic head. The
patient spent two days in the Intensive Care Unit. His
abdominal pain decreased. His nausea and vomiting resolved.
His diet was slowly advanced. He was initially maintained on
antibiotics, Ampicillin, Levofloxacin, Flagyl for possible
abscess in the pancrease. However, the patient remained
afebrile and there was a low suspicion for infection so these
were discontinued. The patient is being discharged on a five
day course of oral Levofloxacin.
2. Alcohol abuse: The patient has a long history of alcohol
abuse. He was maintained on standing Valium to prevent
alcohol withdraw. The patient was strongly advised that he
should quit drinking. He was seen by the addiction service
while in house. The patient is not interested in detox at
this time.
3. Diabetes: The patient has a history of diabetes and is
insulin dependent. Given his hypoglycemia on his previous
admission he was maintained on a cautious regular insulin
sliding scale.
DISCHARGE DIAGNOSES:
1. Hemorrhagic pancreatis.
2. Alcohol abuse.
3. Chronic pancreatitis secondary to alcohol abuse.
4. Diabetes.
5. Depression.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q.d.
2. Viokase three tablets po t.i.d.
3. Wellbutrin 150 mg po b.i.d.
4. Zoloft 100 mg po q.d.
5. Trazodone 200 mg po q.h.s.
6. Levofloxacin 500 mg po q.d. for five days.
7. NPH insulin 10 units subq in the morning.
8. Actos 15 mg po q.d.
DISCHARGE FOLLOW UP: The patient will continue to be
followed by the GI Service. He will see his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within the next week to follow up
on his diabetes management as well as to evaluate his right
groin hematoma, which has been stable while in the hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2130-5-16**] 12:08
T: [**2130-5-17**] 06:25
JOB#: [**Job Number **]
Name: [**Known lastname 2913**], [**Known firstname **] Unit No: [**Numeric Identifier 9236**]
Admission Date: [**2130-5-11**] Discharge Date: [**2130-5-12**]
Date of Birth: [**2084-10-31**] Sex: M
Service: ACOVE Medicine
ADDENDUM: This is an Addendum to the Discharge Summary
covering the admission from [**5-11**] to [**2130-5-12**].
During his stay in the hospital, the patient expressed some
interest in detoxification to deal with his alcoholism. The
patient met with the social worker and was given information
on detoxification facilities. The patient will consider this
option in the future. The patient was advised that he should
stop drinking alcohol.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 225**]
Dictated By:[**Last Name (NamePattern1) 1170**]
MEDQUIST36
D: [**2130-5-12**] 12:11
T: [**2130-5-12**] 12:18
JOB#: [**Job Number 9237**]
|
[
"250.00",
"998.11",
"303.91",
"591",
"442.84",
"997.4",
"577.0",
"577.2",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"44.44"
] |
icd9pcs
|
[
[
[]
]
] |
8466, 8520
|
10906, 11037
|
11060, 11340
|
8052, 8263
|
9717, 10885
|
1824, 2232
|
11352, 12933
|
7080, 7097
|
7126, 7853
|
8535, 9699
|
7875, 8026
|
8280, 8449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,602
| 171,898
|
34462
|
Discharge summary
|
report
|
Admission Date: [**2152-9-14**] Discharge Date: [**2152-9-17**]
Date of Birth: [**2130-4-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
angiogram
History of Present Illness:
HPI: Pt is a 22 yo female w/ no significant PMHx who presents
for
evaluation of SAH. The patient states that 5 days ago she
developed an acute onset [**11-3**] on the back of the head on the R
that migrated down the neck. The headache was throbbing in
nature. She had a bout of emesis. The patient went to the ER
where a head CT was found to be negative. She was offered an LP
but declined. She went home and the headache worsened. She
also
developed simultaneous throbbing of her tail bone whenever her
head would ache. This tail bone aching became so bad that she
could barely walk. She returned to the hospital today where an
LP apparently showed xanthochromia. She was then transferred to
[**Hospital1 18**] for further management.
Past Medical History:
Past Medical History: toxic synovitis in the hips as a child
Social History:
Social History: Recently graduated college. No
ETOH/tobacco/illicits.
Family History:
Family History: paternal grandfather - stroke. maternal
grandmother - brain aneurysm. maternal great grandmother -
brain
aneurysm.
Physical Exam:
Physical Exam:
Vitals: T 97.9; BP 162/91; P 81; RR 14; O2 sat 100% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: mild meningismus
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: awake, alert, relays coherent history. Fluent
speech with no paraphasic or phonemic errors. Adequate
comprehension. Follows simple and multi-step commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. optic discs sharp.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-29**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength throughout.
Sensation: intact to light touch.
Reflexes: 3+ throughout. Toes downgoing bilaterally.
Coordination: FNF intact.
Pertinent Results:
[**2152-9-14**] 12:16AM GLUCOSE-97 UREA N-7 CREAT-0.8 SODIUM-141
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
[**2152-9-14**] 12:16AM WBC-7.7 RBC-4.32 HGB-12.2 HCT-36.5 MCV-85
MCH-28.2 MCHC-33.3 RDW-13.2
[**2152-9-14**] 12:16AM NEUTS-59.7 LYMPHS-31.5 MONOS-4.7 EOS-3.8
BASOS-0.3
[**2152-9-14**] 12:16AM PLT COUNT-243
[**2152-9-14**] 12:16AM PT-13.7* PTT-30.3 INR(PT)-1.2*
Brief Hospital Course:
Pt was admitted to neurosurgery service and monitored closely in
ICU. She went for angiogram that showed no vessel
abnormalities. She had CTA of head and neck also showing no
abnormalities. She continued to c/o headache and low back pain
but it did gradually resolve over course of hospitalization.
She also underwent MRI of the entire spine which ruled out any
spinal AVM. Her neurologic exam remained intact the entire
hospital stay.
Medications on Admission:
Medications: none
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on pain med.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
headache
back pain
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.for one week.
CALL IF YOU EXPERIENCE ANY OF THE FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Please schedule appt to follow up with neurology [**Telephone/Fax (1) 15884**].
Follow up with Dr. [**First Name (STitle) **] for any problems at groin site or as
needed. [**Telephone/Fax (1) 1669**]
Completed by:[**2152-9-17**]
|
[
"784.0",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
3802, 3808
|
2915, 3354
|
325, 336
|
3870, 3893
|
2501, 2892
|
4740, 4970
|
1316, 1434
|
3423, 3779
|
3829, 3849
|
3380, 3400
|
3917, 4717
|
1465, 1758
|
1777, 1777
|
277, 287
|
364, 1111
|
1968, 2482
|
1792, 1952
|
1155, 1195
|
1228, 1284
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,072
| 150,012
|
42066
|
Discharge summary
|
report
|
Admission Date: [**2176-11-25**] Discharge Date: [**2176-12-7**]
Date of Birth: [**2099-2-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo M w/ a h/o HTN, ESRD on PD (question secondary to
Wegner's), PAF (not on coumadin), Lung Ca s/p RU lobectomy, CAD
(60% LAD stenosis found on cardiac cath of [**9-/2176**]), sCHF (EF
35%) taken to [**Hospital3 6592**] for acute on chronic fall and AMS,
who is now transferred to [**Hospital1 18**] for further care.
Pertinently, the following history is obtained by [**Hospital1 **] and [**Hospital3 72204**] discharge summaries: The patient was recently admitted to
OSH ([**10-24**] - [**11-8**]) with several weeks of worsening mental status
and dyspnea. He was clinically volume overloaded and 15L were
removed via CAPD. It was deemed that the patient was not
performing PD appropriately [**3-13**] decline in memory and HD was
recommended by care providers. The patient's family refused and
his wife was noted to be trainned to deliver PD appropriately,
but implementation of this is unclear.
Per discussion w/ patient's wife, Mr. [**Known lastname **] has been getting PD
daily, but missed a few days of PD prior to his last admission.
She also states that in his last admission, patient was treated
for a bacterial infection. She states that over the past few
months, patient has been having difficulty with ambulation, and
has had numerous falls. Since his discharge from [**Hospital 15405**],
patient has fallen at least three times, in the store, shower,
and on day of admission. Since discharge, he was instructed to
use a walker, which he has not been using. She denies episodes
of emesis, fevers, abdominal pain, cough, and headache. She
believs he has had normal bowel movements. He may have had some
chills while at home.
On day of presentation, patient had difficulty walking down the
stairs at his home. He sustained a fall, but wife denies
syncopal episode. She called EMS, who took the patient to [**Hospital1 6591**]. At the OSH he was thought to have R sided weakness and
head CT was "negative." He was transferred to [**Hospital1 18**].
In the ED: VS: T 99.3, BP 204/116, HR 70, RR 20, O2 98% 4L. He
was found to have uremic breath, myoclonic jerks in upper and
lower extremities, and abdominal tenderness. Labs were notable
for Cr 10.3, BUN 68, AGap 28, K 5.5. Ca 7.7, Phos 10.1, WBC 9.4,
HCT 28.0. EKG showed no peaked Ts, TWI inferior leads. UA - WBC
26, RBC 61, Moderate Bacteria, Protein 300. CXR showed pulmonary
edema and with small pleural effusions. Nipride gtt was started
and patient's sbp dropped to 130. The gtt was then stopped and
he received Labetalol 20mg IV. Peritoneal cell count and
cultures were sent. 2g of ceftriaxone was given for suspected
peritonitis.
Past Medical History:
(Per OSH Recs)
- Lung CA - s/p right upper lobectomy
- CAD, recent cath showing 60% LAD w/ EF 35%
- HTN
- Renal Failure, on PD for many years
- Wegner's
- Atrial Fibrilation
- ?recent head bleed
Social History:
- Lives at home with wife
- Previous heavy smoker, quit 10-15 years ago
- ETOH use: 1 beer occasionally, last drank 1 glass of wine two
days ago
- No illicits
Family History:
- No FH of Renal Failure
Physical Exam:
ON ADMISSION:
VS: T 98.5, HR 67, BP 196/82, RR 19, 99% on 3L
GEN: NAD, Patient Awake Orient to Name, and stated that he was
in a "hospital," uremic breath
HEENT: Atraumatic, Normocephalic, MMM, Oropharynx clear, PERRL
NECK: JVD half way to mandible, No LAD, Supple
LUNGS: Crackles at bases L > R, no weezes or rhales
HEART: S1 and S2 present, no m/r/g appreciated
Abdomen: Soft NT/ND, + umbilicle hernia (that's inducible)
Extr: Warm 2+ pulses throughout, no edema
Neuro: Asterixis, myoclonic jerks in both upper and lower and
lower ext. EOMI. Few beats of horizontal nystagmus. Tongue
midline, face symmetric. Tone - normal. No rigidity on exam.
Unable to cooporate w/ cerebellar exam. Moving all extremities,
strength relatively intact throughout. No nuchal rigidity.
DISCHARGE EXAM:
VS: T 78.5, HR 58-65, BP 99-138/59-79, RR 14, 99% on RA
GEN: NAD, Patient AAOx3
HEENT: Atraumatic, Normocephalic, MMM, Oropharynx clear, PERRL
NECK: No JVD elevation, No LAD, Supple
LUNGS: CTAB, no wheezes, rhochi or crackles
HEART: S1 and S2 present, no m/r/g appreciated
Abdomen: Soft NT/ND, + umbilicle hernia (that's inducible), PD
catheter in place
Extr: Warm 2+ pulses throughout, no edema
Neuro: Asterixis resolved, myoclonic jerks in both upper and
lower ext resolved. No rigidity on exam. Motor strength 5/5 in
all extremities
Pertinent Results:
[**2176-11-26**] 08:25AM BLOOD WBC-8.2 RBC-2.73* Hgb-8.1* Hct-25.1*
MCV-92 MCH-29.7 MCHC-32.2 RDW-15.6* Plt Ct-388
[**2176-11-26**] 12:32AM BLOOD Neuts-78.1* Lymphs-12.0* Monos-5.5
Eos-3.9 Baso-0.5
[**2176-11-26**] 08:25AM BLOOD Plt Ct-388
[**2176-11-26**] 08:25AM BLOOD PT-13.8* PTT-27.8 INR(PT)-1.2*
[**2176-11-26**] 08:25AM BLOOD Glucose-102* UreaN-67* Creat-10.1* Na-138
K-3.7 Cl-94* HCO3-24 AnGap-24*
[**2176-11-26**] 12:32AM BLOOD ALT-22 AST-20 CK(CPK)-55 AlkPhos-103
TotBili-0.2
[**2176-11-26**] 08:25AM BLOOD CK-MB-7 cTropnT-0.32*
[**2176-11-26**] 08:25AM BLOOD Calcium-8.3* Phos-10.1* Mg-2.3
[**2176-11-26**] 04:34AM ASCITES WBC-98* RBC-21* Polys-10* Lymphs-1*
Monos-86* Eos-1* Mesothe-1* Other-1*
[**2176-11-25**] 11:00PM ASCITES WBC-610* RBC-100* Polys-21* Lymphs-1*
Monos-75* Eos-1* Mesothe-1* Other-1*
[**2176-11-25**] 10:40PM URINE RBC-61* WBC-26* Bacteri-MOD Yeast-NONE
Epi-0 TransE-2
[**2176-11-26**] 08:25AM BLOOD VitB12-660 Folate-17.2
[**2176-11-26**] 08:25AM BLOOD TSH-5.0*
[**2176-11-25**] 10:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
MICRO:
[**2176-12-2**] 12:51 pm DIALYSIS FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2176-12-2**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
[**2176-11-25**] 11:00 pm PERITONEAL FLUID
GRAM STAIN (Final [**2176-11-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2176-11-29**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH
URINE CULTURE (Final [**2176-11-27**]): NO GROWTH.
[**2176-11-26**] 4:34 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2176-11-26**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2176-11-29**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
RAPID PLASMA REAGIN TEST (Final [**2176-11-27**]):
NONREACTIVE.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2176-11-29**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2176-11-29**] 12:19 pm PERITONEAL FLUID
GRAM STAIN (Final [**2176-11-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING:
CXR ([**2176-11-25**]):
IMPRESSION: Mild congestive heart failure with small bilateral
pleural effusions. Patchy opacities in the lung bases may
reflect atelectasis.
CT head (from OSH): "negative" per ED report
[**2176-11-30**] 10:37PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
[**2176-11-30**] 10:37PM URINE RBC-17* WBC-25* Bacteri-FEW Yeast-NONE
Epi-1
DISCHARGE LABS:
[**2176-12-7**] 07:20AM BLOOD WBC-10.8 RBC-3.78* Hgb-11.8* Hct-35.1*
MCV-93 MCH-31.2 MCHC-33.6 RDW-14.9 Plt Ct-458*
[**2176-12-7**] 07:20AM BLOOD Plt Ct-458*
[**2176-12-7**] 07:20AM BLOOD Glucose-132* UreaN-73* Creat-9.0* Na-131*
K-4.2 Cl-90* HCO3-28 AnGap-17
[**2176-12-7**] 07:20AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.9*
Brief Hospital Course:
77M presented with mental status change s/p fall w/ labs notable
for Cr 10.3, K 4.3, AG 23 in the setting of complicated PMH
including (ESRD, HTN, AFib, Lung CA, CAD). Mental status
improve over time. Hospitalization course complicated by C.
diff and afib with RVR.
# Altered Mental Status: Initially presented to MICU AAO x1.
Presented with symptoms suggestive of toxic/metabolic
encephalopathy (asterixis, myoclonus) however we felt his PD was
working currently and uremia did not seem to be an obvious
etiology. He was treated empirically for potential peritonitis
with vancomycin intraperitoneal and ceftriaxone IV. Peritoneal
fluid cultures were negative and WBC <50, so antibiotics were
discontinued. He had a negative head CT. His serum/urine tox,
LFTs, ABG were negative. B12, folate in normal limits. Stool +
C. diff toxin, treated with 2-week course of PO vanc (last day
[**12-12**]). Mental status slowly improved to baseline of AAOx3.
There has been ongoing concern that this patient has been
failing to do PD properly at home, and this may have been the
cause of his delirium. He was Alert and oriented x 3 by the
time of discharge, but did still demonstrate lapses in long term
recall, suggesting some underlying dementia. We discussed with
his [**Month/Day (4) 3390**] our feelings that PD may not be the best choice for this
patient given his likely underlying dementia, and that he would
benefit from more clear neuropsychiatric testing for diagnosis
and treatment after discharge from the hospital.
# ESRD: ESRD [**3-13**] Wegeners on peritoneal dialysis. Cr in ED was
10.3 (baseline unclear). PD with 2.5 % dextrose, [**2165**] ml volume,
6 hr dwell, 4 cycles in 24 hours. Pt was maintained on PD, his
creatinine trended downwards.
# Hypertension: Blood pressure elevated on admission. IV
labetolol used initially in MICU. Became bradycardic so he was
switched to hydralazine IV q 6hr. Eventually re-started on his
home antihypertensives - lisinopril, imdur, amlodipine,
metoprolol (as per home regimen). Still hypertensive, but low
BP after all his morning meds, decreased AM lisinopril to 20mg
and increased Imdur from 60mg to 90mg to be taken at night
instead of in the morning. After patient developed a-fib, we
uptitrated his metoprolol and discontinued all other
antihypertensives. Consider restarting lisinopril, imdur and
amlodipine at rehab.
# AFib: EKG and tele showed sinus rhythm on admission. On
[**12-4**], patient went into rapid afib with rates in 140s,
orthostatic hypotension and became unresponsive for a few
seconds on standing, which resolved with lying down. No EKG
evidence of ACS. No fever or other source of infection, C. diff
under treatment. TSH elevated, but in the setting of acute
illness, no history of thyroid pathology. Initially rate
controlled with IV metoprolol 5mg, then transitioned to
metoprolol 50mg TID. Overnight on [**12-4**], spontaneously
converted to sinus rhythm with rates in 50-60s with metoprolol.
Discharged on metoprolol succinate 100mg daily. Patient
continued on ASA 325mg. Coumadin anticoagulation considered
given CHADS score of 3. However, given patient's multiple falls
and history of head bleed, as well as some question of
medication non-compliance, did not start anticoagulation due to
high risk of recurrent fall.
# CAD: Recent cath showing 60% LAD w/ EF 35%. Patient currently
not complaining of CP, EKG notable for conduction abnormalities
that are unchanged from prior. His troponin was initially
elevated at 0.3 but remained stable likely due to ESRD. On
[**2176-12-1**], complained of some epigastric/chest pain in the
setting of repeated emesis. ECG was performed, subtle ST
depressions in V1, V2 which looked changed from prior however in
the setting of old RBBB. Troponins remained baseline of 0.3, so
low suspicion for cardiac etiology, more likely acid reflux.
Repeat EKG back to baseline.
# C.diff - Profuse diarrhea, C. Diff positive. Pt started on PO
vanc on [**11-29**] for 14-day course (last day [**12-12**]). Diarrhea
resolved in a few days. On [**2176-12-1**] pt developed continuous
persistent hiccups, burping, and flatus, with distended (but not
tense and completely without pain) tympanic abdomen. KUB was
obtained which showed no evidence of obstruction or ileus.
# Leukocytosis - Flucuating WBC during hospitalization,
initially corresponds to C. diff infection, but WBC increased
again after resolving. Pt has UA with UTI looking profile -
hesitant to treat because he appears to always have leukocytes
in urine, denies dysuria. Urine cx [**Numeric Identifier 961**]-[**Numeric Identifier 4856**] enterobacter and
enterococcus. Have considered peritonitis but have evaluated
peritoneal fluid twice and most recently [**2176-11-29**] with no
evidence of peritonitis on cell count and no growth. CXR clear.
TRANSITIONAL ISSUES:
1. Hypertension: At the time of discharge, patient's blood
pressure was stable with SBP 100-150 on metoprolol. He will
continue on Metoprolol succinate 100mg daily upon discharge.
Please monitor BP at rehb. Can add back amlodipine, imdur,
lisinopril if required for better blood pressure control.
2. Please check Chem 7 in 1 week (on [**2176-12-13**]). Patient has
been hyponatremic, likely secondary to dialysis, but requires
monitoring. Please maintain fluid restriction to 1.5 L/day.
3. Patient continues on PO vancomycin for treatment of C. diff
colitis. Last day of treatment [**2176-12-12**].
4. Incidental findings on CXR please get chest CT for follow up
5. Please follow up thyroid function test TSH was 5.0, but in
the setting of illness could not effectively evaluate.
6. Memory impairment: patient noted to have memory impairment.
Concern that he and his wife will be unable to cope with
peritoneal dialysis at home by themselves, may benefit from
transitioning to hemodialysis in the future. This has been
communicated to wife and [**Month/Day/Year 3390**]. [**Name10 (NameIs) 3390**] to followup.
Medications on Admission:
- Nephrocaps 1 QD
- Lisinopril 40 daily
- Cholecalciferol 5000 units QD
- Amlodipine 10 QD
- Ipratropium, duoneb Q2-4H
- percocet 1 tab
- metoprolol 25mg [**Hospital1 **]
- selevamir
- imdur 60mg daily
Discharge Medications:
1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days: last day [**12-12**].
2. cholecalciferol (vitamin D3) 5,000 unit Tablet Sig: One (1)
Tablet PO once a day.
3. famotidine 40 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. dialysis Sig: daily daily: Peritoneal Dialysis orders
2.5 % dextrose
[**2165**] cc volume
Dwell time 6 hours, 4 cycle in 24 hours
Please note effluent color, consistency, volume
Monitor i/o, weights.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
PRIMARY:
Fall
C. diff colitis
CKD on Peritoneal dialysis
Altered mental status
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization. You were admitted after you fell and became
confused. Your head CT did not show any signs of bleeding. We
continued your peritoneal dialysis while you were in the
hospital. We also found that you have C. diff, an infection of
your intestines. We are treating this with antibiotics
(Vancomycin).
You had an episode of rapid heart rate. We increased your
metoprolol and changed some of your other blood pressure
medications.
We made the following changes to your medications:
STARTED Vancomycin (last day [**2176-12-12**])
STARTED Famotidine
CHANGED Metoprolol to 100mg extended release daily.
STOPPED Imdur
STOPPED Lisinopril
STOPPED Amlodipine
STOPPED Duonebs
STOPPED Percocet
STOPPED Ipratropium
Followup Instructions:
Please follow up with your [**Month/Day/Year 3390**], [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], 1-2 weeks after
you return home from rehab.
Completed by:[**2176-12-7**]
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[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,436
| 163,621
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28450+57594
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-1-20**] Discharge Date: [**2140-1-29**]
Date of Birth: [**2074-10-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
Trauma: fall:
Open book pelvis
Sacral fxs
T5-6 vertebral body fx
Post rib fx 5 & 6
Major Surgical or Invasive Procedure:
[**2140-1-23**] ORIF pelvis
[**2140-1-22**] VATS evacation of hematoma
[**2140-1-21**] Left chest tube placement
[**2140-1-20**] IR embo R int iliac artery bleeders
History of Present Illness:
This patient is a [**Age over 90 **] year old male who was transferred from
[**Hospital6 204**] after a FALL down the stairs. The
patient was brought to LGH where pelvis xray showed pelvis
fracture. CT scan showed hematoma. Pt was hypotensive upon
transfer and was hypotensive on arrival. He was transferred to
the TSICU for further management of his pelvic fracture and
hypotension.
Past Medical History:
PMH: Parkinson's disease, hypertension GERD, BPH, osteoporosis
PSH: L inguinal herniorrhaphy x 2, R inguinal herniorrhaphy x 2
Social History:
Lives with wife [**Name (NI) 37327**]. Non-smoker, No EtOH
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAMINATION: upon admission [**2140-1-20**]
BP:90s/40 Resp:24 O(2)Sat:100 Normal
Constitutional: pale, GCS 14
HEENT: perrla, EOMI
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: firm abdomen, tender to palpation diffusely,
FAST +
GU/Flank: No costovertebral angle tenderness
Physical Exam upon discharge [**2140-1-29**]
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2140-1-29**] 05:05 17.0* 3.74* 11.4* 33.3* 89 30.4 34.1 14.3
246
[**2140-1-28**] 05:53AM BLOOD WBC-13.3* RBC-3.50* Hgb-10.6* Hct-30.3*
MCV-87 MCH-30.2 MCHC-34.9 RDW-14.2 Plt Ct-243
[**2140-1-27**] 02:40AM BLOOD WBC-11.4* RBC-3.21* Hgb-10.3* Hct-27.9*
MCV-87 MCH-32.1* MCHC-36.9* RDW-14.3 Plt Ct-202
[**2140-1-26**] 02:29AM BLOOD WBC-13.1* RBC-3.40* Hgb-10.3* Hct-29.5*
MCV-87 MCH-30.3 MCHC-35.0 RDW-14.5 Plt Ct-158
[**2140-1-28**] 05:53AM BLOOD Plt Ct-243
[**2140-1-27**] 02:40AM BLOOD Plt Ct-202
[**2140-1-26**] 02:29AM BLOOD Plt Ct-158
[**2140-1-23**] 02:44AM BLOOD PT-14.5* PTT-30.6 INR(PT)-1.3*
[**2140-1-22**] 07:05AM BLOOD Fibrino-271#
[**2140-1-20**] 08:15PM BLOOD Fibrino-159
[**2140-1-28**] 05:53AM BLOOD Glucose-97 UreaN-26* Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
[**2140-1-27**] 02:40AM BLOOD Glucose-115* UreaN-32* Creat-0.7 Na-144
K-3.5 Cl-108 HCO3-30 AnGap-10
[**2140-1-26**] 02:29AM BLOOD Glucose-119* UreaN-30* Creat-0.7 Na-140
K-3.8 Cl-106 HCO3-27 AnGap-11
[**2140-1-28**] 05:53AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.1
[**2140-1-27**] 02:40AM BLOOD Calcium-7.3* Phos-2.3* Mg-2.1
[**2140-1-26**] 02:29AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.2
[**2140-1-24**] 09:18AM BLOOD O2 Sat-94
[**2140-1-25**] 12:34PM BLOOD freeCa-1.16
[**2140-1-24**] 05:49PM BLOOD freeCa-1.07*
[**2140-1-20**]: EKG:
Sinus rhythm. Left axis deviation. There is diffuse ST segment
elevation and PR segment depression raising the question of
pericardial process. No previous tracing available for
comparison. Clinical correlation is suggested
[**2140-1-20**]: Chest x-ray and pelvis:
IMPRESSION: Pubic symphysis diastasis. Please refer to outside
hospital CT
for further details regarding traumatic injuries.
[**2140-1-20**]: Angiography:
FINDINGS:
1. There is diastasis of the pubic symphysis seen.
2. In the visualized field no regions of abnormal active blush
are noted (the field did not include the lower part of the
pelvis including )
[**2140-1-20**]: Angiography:
IMPRESSION:
1. Right common iliac, selective internal iliac, selective
obturator and
internal pudendal arteriograms demonstrating abnormal focal
arterial blushes in the region of the lower pelvis close to the
medial border of the right inferior pubic rami,arising from
distal branches of the right obturator and internal pudendal
arteries.
2. Successful coil embolization performed in the right obturator
and the
internal pudendal arteries, followed by administration of
gelfoam slurry
[**2140-1-21**]: cat sca of the c-spine:
IMPRESSION:
1. No fracture or malalignment in the c spine. Multilevel
bilateral neural
foraminal narrowing, most prominent at the levels of C5-C6,
moderate in
degree. If there is concern for cord, ligamentous/neural injury,
MR can be
considered if not contra-indicated.
2. Extensive opacification occupying the entire visualized left
lung apex
significantly increased since Reference CT from one day prior,
inadequately characterized. Consider dedicated chest imaging.
3. 2.2cm mass in the right side of the upper neck - ? nodal
mass/ other
etiology/ related to the submandibular gland- correlate with
ultrasound
[**2140-1-21**]: cat scan of the head:
IMPRESSION: Left parietal scalp hematoma. No acute intracranial
hemorrhage.
However,a ssessment for subtle hemorrhage is limited from recent
contrast admn at embolization procedure. Consider follow up in
12 hours for better
assessment if clinically indicated
[**2140-1-22**]: Chest x-ray:
IMPRESSION: Increasing left upper lung opacity, concerning for
re-accumulating hemothorax.
[**2140-1-23**]: Chest x-ray:
FRONTAL CHEST RADIOGRAPH: The endotracheal tube is again high
lying,
approximately 11 cm from the carina and should be advanced for
optimal
placement. There are two apically coursing left-sided chest
tubes and one
basal chest tube in unchanged positions. The opacity at the left
lung apex is stable. The cardiomediastinal silhouette is stable.
There is mild vascular congestion as well as bilateral pleural
effusions and atelectasis mildly increased on the right.
[**2140-1-23**]: Abdominal fluro:
IMPRESSION:
Status post ORIF of the pubic symphysis. Possible left medial
fractured screw as above
[**2140-1-24**]: chest x-ray:
FINDINGS: The lateral most chest tube on the left side has
removed. There
are two persistent chest tubes on the left side. There is no
residual
pneumothorax. The endotracheal tube, feeding tube, and
left-sided central
venous catheter are unchanged in position and appropriately
sited. There is a persistent left retrocardiac opacity and
bilateral pleural effusions, right side slightly greater than
left. There is again unchanged prominence of the pulmonary
interstitial markings. No pneumothoraces are present on either
side
[**2140-1-25**]: Chest x-ray:
There may be a slight increase in the volume of pleural fluid
collected
laterally since 8:35 a.m. today following removal of the left
apical pleural drain, but there is no pneumothorax. Aeration in
the left lower lobe has improved, but there is still substantial
residual atelectasis at the right lung base and generalized
pulmonary vascular and mediastinal venous engorgement suggesting
mild cardiac decompensation. Heart size is borderline enlarged
but unchanged acutely. No pneumothorax. Left subclavian line
ends in the SVC
[**2140-1-28**]: chest x-ray:
Interval removal of NGT and L subclavian CVL. NO PTX. Improved
upper lung aeration, but with persistent R basilar atelectasis.
Persistent
left retrocardiac opacity could represent combination of pleural
effusion,
atelectasis or focal air- space consolidation.
[**2140-1-24**] 8:56 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2140-1-26**]**
GRAM STAIN (Final [**2140-1-24**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2140-1-26**]):
SPARSE GROWTH Commensal Respiratory Flora.
MORAXELLA CATARRHALIS. HEAVY GROWTH
[**2140-1-24**]: urine culture:
[**2140-1-24**] 8:55 am URINE Source: Catheter.
**FINAL REPORT [**2140-1-25**]**
URINE CULTURE (Final [**2140-1-25**]): NO GROWTH
[**2140-1-29**]:
[**2140-1-29**] 10:45 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
65 year old gentleman admitted to the Acute Care service after
falling down stairs. Upon admission, he was made NPO, given
intravenous fluids, and had imaging studies. He sustained a
open pelvic fracture, sacral fracture, rib fractures, and T5-6
vertebral body fracture. He was monitored in the intensive care
unit where he was hypotensive and on [**1-21**] he was transfused 3u
PRBC for acute blood loss anemia. He was taken to the IR suite
to identify the source of bleeding and underwent angio
embolization of the right internal iliac artery branch bleeders.
Post procedure he was noted to have increased respiratory effort
and chest xray demonstrated a L hemothorax for which a L chest
tube was placed. Overnight he hecame hypotensive and was noted
to have large output from the CT. He was taken to the OR for
eval of bleeding in L chest by Thoracic surgery on [**1-22**] where he
received an additional 4 units of PRBCs, 2 FFP, and 1 plts for
acute blood loss anemia. No apparent source of bleeding was
identified. He tolerated the procedure well and returned to the
TSICU in fair condition. Post op his hct was stable but was
given 1 unit PRBCs and multiple fluid boluses for hypotension
with good response. On [**1-23**] pt was taken to the OR by ortho for
anterior ORIF pelvis. He received 2u PRBC intra-op. Post op he
again returned to the TSICU in stable condition requiring fluid
boluses to maintain his pressures above 100 mmHg systolic.
He was evaluated by speech and swallow on [**1-25**] but was unable to
adequately protect his airway. A dobhoff tube was subsequently
placed and tube feeds were started following confirmation of
tube placement with abd XR. The Chest tubes were removed and his
HCT was noted to remain stable. SQH was started on [**1-25**] pm. Pt
was transfered to the floor on [**1-26**] where he was started on lasix
for net fluid overload and began to disuresis adequately (net
neg 1-2L). On the floor he worked with PT [**Name (NI) 11030**] on BLE per
ortho) and was recommended rehab for discharge. The patient was
cared for by the rotating services of the acute care surgical
team.
At the time of discharge pt was in stable condition, tolerating
tube feeds at 60cc/hr
His tube feedings were discontinued.
The patient was transfered to the regular floor on [**1-27**]. He did
have periods of confusion, but cleared with re-orientation. He
was evaluated by speech and swallow and a regular diet was
recommended. He has been tolerating a regular diet, but needs
assistance with meals. Physical therapy and occupational
therapy were consulted and recommended assistance of 2 when
ambulating and hand assistance with meals. Over the last 24-48
hours, he has had a slow increase in his WBC count up to 17.0.
He did have a sputum culture on [**1-24**] which grew Morxella
catarrhalis. A chest x-ray was done [**1-28**] which showed a
persistent retro-cardiac opacity. Because of these recent
findings, he has been started on a 10 day course of
levofloxacin.
He is preparing for discharge to an extended care facility. He
has been afebrile. His vital signs are stable. He is voiding
without difficulty and has moved his bowels. He has ambulated
with assistance without shortness of breath. He is conversant
and cooperative with daily activities. He has been evaluated by
Neurology for his episodes of confusion and it felt that his
confusion was related to his overall illness and narcotics and
should improve.
He will need to follow-up with the Acute Care service in 2 weeks
and Orthopedics. He will also need to follow-up with Dr. [**Last Name (STitle) **]
in the Movement [**Hospital 2980**] clinic.
Medications on Admission:
[**Last Name (un) 1724**]: acebutolol 400', alendronate 70 weekly, alfuzosin 10',
aspirin 81 QOD, carbidopa-levodopa 50-200"', diazepam 2.5-5 QHS
PRN insomnia, esomeprazole 40', venlafaxine 112.5', calcium,
vitamin D
Micro/Imaging:
Discharge Medications:
1. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for diarrhea.
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for systolic blood pressure <110, hr <70.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection three times a day.
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. alfuzosin 10 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
9. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
10. diazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day: 10 day course ( to start today [**1-29**]).
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-2**]
hours: as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] rehabilition
Discharge Diagnosis:
Open book pelvic fracture
Sacral fxs
T5/T6 vertebral body fracture
[**4-1**] post rib fracture
Hemothorax s/p L VATS and evacuation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after you fell down stairs.
You sustained a pelvic fracture, rib fracture, fracture of your
thoracic spine. You were evaluated by Orthopedics and you went
to the operating room for repair of your pelvic fracture. You
also had a bleed into your chest and you had the collection of
fluid removed. You are preparing for discharge with the
following instructions:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, YOU ARE ALLOWED 50% WEIGHT BEARING TO
BILATERAL LOWER EXTREMITIES. YOU [**Month (only) **] STAND BUT NOT AMBULATE.
Please drink adequate amounts of fluids. Avoid driving or
operating heavy machinery while taking pain medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Please follow up with the Acute Care Service in 2 weeks. You
can schedule your appointment by calling #[**Telephone/Fax (1) 600**].
Please follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 19448**] # [**Telephone/Fax (1) 1228**] 2 weeks
for Ortho follow-up. Please schedule this appointment
Please follow up with the Movement [**Hospital 2980**] Clinic, Dr. [**Last Name (STitle) **],
in [**1-29**] weeks. You can schedule this appointment by calling
#[**Telephone/Fax (1) 1942**]
Completed by:[**2140-1-29**] Name: [**Known lastname 11786**],[**Known firstname **] C Unit No: [**Numeric Identifier 11787**]
Admission Date: [**2140-1-20**] Discharge Date: [**2140-1-29**]
Date of Birth: [**2074-10-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11788**]
Addendum:
Physical Examination upon discharge: [**2140-1-29**]:
Vital signs: t=96.3, hr=80, bp=112/62, resp. rate 18, oxygen
saturation RA 98%
General: Sitting in chair, conversant, NAD
CV: Ns1, s2, s-3, s-4
LUNGS: Crackles bases bil.
ABDOMEN: Soft, non-tender, staple line lower abdomen clean and
dry
EXT: Hyperpigmentation lower ext. bil., feet cool, no pedal
edema, + dp bil
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] rehabilition
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 11789**] MD [**MD Number(2) 11790**]
Completed by:[**2140-1-29**]
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icd9cm
|
[
[
[]
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] |
[
"88.49",
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"96.6",
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"34.09",
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icd9pcs
|
[
[
[]
]
] |
16887, 17108
|
8193, 11840
|
390, 557
|
13529, 13529
|
1707, 8134
|
15569, 16510
|
1217, 1236
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12124, 13270
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13374, 13508
|
11866, 12101
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13705, 15009
|
1251, 1251
|
8170, 8170
|
1273, 1687
|
15041, 15546
|
265, 352
|
16527, 16864
|
585, 971
|
13544, 13681
|
993, 1124
|
1140, 1201
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,488
| 199,018
|
1336
|
Discharge summary
|
report
|
Admission Date: [**2174-12-18**] Discharge Date: [**2174-12-22**]
Date of Birth: [**2103-11-29**] Sex: F
Service: MICU-Green
CHIEF COMPLAINT: Hypercarbic respiratory failure.
HISTORY OF PRESENT ILLNESS: This is a 71 year old female
with a history of COPD requiring home oxygen. EMS were
called this morning due to her increased dyspnea. The
patient has been complaining of increasing dyspnea, cough
with productive sputum for the last three days with increased
frequency of home 02 use. The patient was started on
Levofloxacin on [**2174-12-15**] by her primary care physician without
improvement in her symptoms. Also complaining of mild
intermittent fevers and chills without nausea, vomiting,
diarrhea or abdominal pain. She did have decreased po intake
per daughter who lives with her. No change in status when
she went to bed last night. This morning the patient awoke
and was markedly worse. At that time EMS was called and they
found the patient to be tachycardic at 122 with a blood
pressure of 140/40 with an oxygen saturation of 85% on four
liters nasal cannula which improved to 100% on 100%
nonrebreather.
On arrival in the Emergency Room, the patient's blood
pressure was elevated. She was tachycardic and mildly
tachypneic with an oxygen saturation of 79% on room air and
99% on 100% nonrebreather. She was diffusely wheezy on
auscultation. She was given back to back nebulizer
treatments, briefly placed on BiPAP with no improvement in
her clinical status. Thus she was intubated for hypercarbic
respiratory failure. She received 1 gram of Ceftriaxone and
125 mg of Solu-Medrol. She also received intermittent IV
boluses of normal saline for blood pressure support.
PAST MEDICAL HISTORY:
1. COPD, on home 02.
2. History of DVT treated in the past with Coumadin.
3. Congestive heart failure.
4. Hypertension.
5. History of pneumonia in [**2174-8-30**].
6. History of tachyarrhythmia.
7. Transthoracic echocardiogram in [**2173-12-31**] showed
ejection fraction of 70% with mild to moderate right
ventricular dilation, marked right atrial dilation with a PEA
pressure of 70, 2 to 3+ tricuspid regurgitation, 1+ aortic
insufficiency and 1+ mitral regurgitation.
ALLERGIES: No known drug allergies.
MEDICATIONS: Diltiazem extended released 120 mg po q day,
Digoxin 0.125 mg po q day, calcitrol 0.25 mg tid, Protonix 40
mg po q day, home oxygen, Albuterol, potassium chloride 10
mEq po q day, prednisone 10 mg po q day. It is not known if
this is part of a taper or if the patient is on this
chronically. Calcium 500 mg po q day, Lasix 40 mg po q day,
Flovent 220 q day, Combivent two puffs [**Hospital1 **].
SOCIAL HISTORY: The patient lives with husband and daughter,
denies recent tobacco use but does have a 25 to 30 year
history of remote tobacco use, reportedly heavy tobacco use.
PHYSICAL EXAMINATION: Temperature 98.0 F, pulse 96, blood
pressure 99/47, respiratory rate 15. Vent settings: AC
14/400/0.5.
Neurological: The patient is intubated and sedated. HEENT:
No icterus, no pallor. Mucous membranes are moist, no
pharyngeal lesions or exudates. Neck: Supple, no
lymphadenopathy. Cardiovascular: Tachycardic, regular
rhythm, no rubs, gallops or murmurs, no jugular venous
distention, no peripheral edema. Pulmonary: Lungs clear to
auscultation with expiratory wheezes and decreased breath
sounds throughout. Abdomen: Soft, nontender, nondistended
with positive normal bowel sounds. Extremities cool with 1+
dorsalis pedis radial pulses bilaterally.
PERTINENT DATA ON ADMISSION: White blood cell count 17.3,
hematocrit 48.4, platelets 354, 59% neutrophils, 20%
lymphocytes, 17% monocytes. INR 0.9, PTT 26.7, sodium 137,
potassium 3.3, chloride 93, bicarbonate 35, BUN 16,
creatinine 0.6, glucose 168. Blood gas upon presentation
prior to intubation was 6.99/198/109. Post-intubation the
patient's blood gas was 7.34/71/229. Urinalysis showed [**5-9**]
white blood cells with occasional bacteria and no epithelial
cells.
Chest x-ray showed patchy right middle lobe density.
EKG showed sinus tachycardia at 103 with nonspecific T wave
changes in V6.
HOSPITAL COURSE: The patient was advised to the Intensive
Care Unit with initial vent settings of AC 16/400/40%/5 with
a peak inspiratory pressure of 37.5. She was started on IV
Solu-Medrol, q six hour Albuterol and Atrovent nebulizer
treatments, Ceftriaxone and Levaquin and was sedated with
Ativan while on the ventilator. She remained hemodynamically
stable throughout hospitalization. She was given maintenance
IV fluids. Her Digoxin was continued.
On hospital day two the patient was switched to pressure
support which she tolerated well and on hospital day three
the patient was extubated. She tolerated extubation well.
Per the patient's daughter, she gets very anxious and
claustrophobic relatively easily. On several occasions
post-extubation the patient became acutely tachycardic,
mildly hypertensive and tachypneic without significant
changes in her oxygen saturation or in her arterial blood
gas. She was placed on BiPAP briefly for two of these
episodes and was eventually treated with IV Ativan for
anxiety. She did not require BiPAP support for greater than
24 hours prior to discharge. She had a triple lumen catheter
as well as an arterial line in place during this
hospitalization.
Blood cultures, sputum cultures and urine cultures failed to
show any growth. After extubation the patient was restarted
on her daily Diltiazem and Lasix at her prior outpatient
doses for blood pressure control. At the time of discharge
and for the 24 hours prior, the patient was breathing
comfortably on a nasal cannula of 2 to 3 liters. The patient
was also provided with DVT and GI prophylaxis while in the
Intensive Care Unit with subcutaneous Heparin and IV Pepcid.
Her arterial blood gas on the morning of [**2174-12-21**] was
7.42/66/97%. The patient is a chronic CO2 retainer.
Both antibiotics, Ceftriaxone and Levaquin, were started on
[**2174-12-18**]. The Levaquin is to be continued for at least 10
days. The patient's arterial line and triple lumen catheter
were also both placed on [**2174-12-18**]. The patient was kept on a
regular insulin sliding scale, given that she was on a
significant dose of steroids. She does not have a prior
history of diabetes mellitus.
DISCHARGE STATUS: The patient is stable for transfer to
pulmonary rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcu q 12 hours.
2. Pepcid 20 mg po bid.
3. Albuterol nebulizers q 6 hours prn.
4. Atrovent nebulizers q 6 hours prn.
5. Levaquin 500 mg po q day to be completed with her last
dose on [**2174-12-27**].
6. Salmeterol two puffs [**Hospital1 **].
7. Colace 100 mg po bid.
8. Senna one tablet po bid.
9. Digoxin 0.125 mg po q day.
10. Lasix 40 mg po q day.
11. Diltiazem extended release 120 mg po q day.
12. Flovent 220 mcg two puffs [**Hospital1 **].
13. Atrovent two puffs qid metered dose inhaler.
14. Regular insulin sliding scale.
15. Prednisone taper from 50 mg to 10 mg to be decreased by
10 mg every three day.
DISCHARGE DIAGNOSES:
1. COPD exacerbation.
2. Pneumonia.
3. History of DVT treated with Coumadin in the past.
4. CHF.
5. Hypertension.
6. History of pneumonia.
7. History of tachyarrhythmia.
8. Echocardiographic findings consistent with hyperdynamic
left ventricular function, mild to moderate right ventricular
dilation, marked right atrial dilation, elevated pulmonary
arterial pressures, 2 to 3+ tricuspid regurgitation, 1+
aortic insufficiency and 1+ mitral regurgitation.
On the day of discharge, the patient's white blood cell count
was 16.3 with 60% neutrophils, hematocrit 39.4, creatinine
0.3, BUN 24, Digoxin level drawn on [**2174-12-21**] was 0.6.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697
Dictated By:[**Last Name (NamePattern1) 7120**]
MEDQUIST36
D: [**2174-12-21**] 21:59
T: [**2174-12-21**] 21:43
JOB#: [**Job Number 8169**]
|
[
"396.3",
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"458.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"93.90",
"96.04",
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] |
icd9pcs
|
[
[
[]
]
] |
7135, 8022
|
6465, 7114
|
4163, 6442
|
2872, 3554
|
160, 194
|
223, 1717
|
3569, 4145
|
1739, 2669
|
2686, 2849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,594
| 145,912
|
28481
|
Discharge summary
|
report
|
Admission Date: [**2186-10-3**] Discharge Date: [**2186-12-13**]
Date of Birth: [**2137-1-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Bilateral lower extremity ischemia.
Major Surgical or Invasive Procedure:
B/L CIA stents, Right EIA stent
Mediastinoscopy
Lung Cancer
History of Present Illness:
49 y/o homeless male with history of severe PVD, DM,
alcoholism, and COPD who was transferred from [**Hospital 1474**] Hospital
on [**10-3**] for management of RLE ulcer and cellulitis.He has
undergone iliac stent placement (b/l CIA, R EIA) with an
extended PACU course However his pre-operative work-up reveled
two opacities in the LUL. The more superior opacity is the
denser
of the two measuring approximately 2.5 x 1.3 cm. Just inferior
to this, is a less dense more ill-defined area of spiculated
opacity, measuring 1.7 x 1.4 cm. The patient has undergone a
full staging work-up with cervical mediastinoscopy, that
revealed
to evidence of malignancy in the nodes, a PET scan that revealed
FDG avid disease only in the LUL and a head MRI that was within
normal limits. The initial plan was to have him undergo a LUL
lobectomy. However, given his poor pulmonary function, thoracic
surgery does not feel that he is a good candidate for resection.
Therefore, oncology was consulted to help with non-surgical
management.
Past Medical History:
PAST PSYCHIATRIC HISTORY: Mr. [**Name13 (STitle) 3100**] reports having "PTSD" and
sees Dr. [**Last Name (STitle) 29306**] [**Name (STitle) 69038**] (p. [**Telephone/Fax (1) 69039**]) at [**Location (un) **]
Counseling Ctr. Dr. [**Last Name (STitle) 69038**] prescribes Ritalin 60 mg daily and
Seroquel 600 mg daily for the patient, which he had been taking
up until just a few weeks before coming into the hospital. It
was not clear why he was taking these medications. He says of
his traumatic childhood, "I was 6 [**1-30**] when my sister and I
returned from [**Hospital 1474**] Hospital after having our tonsils out,
and
there was a surprise. My old man blew his head off. There was a
trail of blood. He was cold and [**Doctor Last Name 352**] on the bed in the master
bedroom." He says that his childhood was rough and implied
physical abuse by some, but not all members of his immediate
family. A brother reportedly broke his back and on another
occasion both shoulders by holding his hands behind his back
until "he would give" when he was 8.5 years old. At that time
he
thought about suicide, but never since, by his report.
He denies nightmares, flashback or hypervigilance. Of his
"PTSD"
he alludes to his childhood and says that sometimes he "will see
something on the boob tube that will make me freeze up." The
last time that he had suicidal ideation was at 8 yo.
He says, "I don't have paranoia. ...I've never had audio or
visual hallucinations." He mentions a time when he would tape
conversations with his sister to have a record of their
exchanges, although it was not clear why he was doing this
(?paranoia of some sort). Mr. [**Known lastname 6203**] does have a h/o DMH
services, at least suggesting some more chronic mental illness.
.
PAST MEDICAL HISTORY:
Perforated Duodenal Ulcer 1.5 years ago
Acute pancreatitis 1.5 years ago
Patient was hospitalized for mgmt of these conditions, he sought
hospitalization out on his own for treatment.
Social History:
SOCIAL HISTORY: Information was limited. Per Mr. [**Known lastname 6203**], he
grew up in [**Hospital1 1474**] in a troubled home, the youngest of several
siblings. Pls see Past Psych Hx above for add'l detail. He
went
to vocational school in Southern [**State 1727**], learning to be a
engineering/technical drafter and worked for the Navy "running
ships." He did not actually serve in the military. He married
his girlfriend of 10 years, but the marriage only lasted 9 mos.
They divorced because of his drinking and her spending problems
and a disagreement on having children. He has no children. He is
no longer in touch with any family or friends, although he
reportedly has a brother who lives in the area. He said his
sister lives in [**Name (NI) 61361**] CO. He says that he does "get along with
people," citing nursing staff as an example. He lived in a
boarding house until 1.5 years ago when he "got the boot" but
declined to elaborate, getting angry when inquiry was made. He
has been living in his care since then. Social work notes
indicate that his mother perhaps died sometime around one year
ago.
Family History:
non contributary
Physical Exam:
MENTAL STATUS EXAM:
Appearance: Mr. [**Known lastname 6203**] lies on the bed writhing and groaning
in pain. He is pale and thin, appearing older than his stated
age. He has hoarded food and stationary in his room. There is
a
log of meds in his handwriting at the bedside.
Language: monotone, slow rhythm, appropriate volume, slightly
garbled but comprehendible
Mood: "non-committal" explaining he says "I've been on a
down-[**Hospital1 **] spiral"
Affect: Restricted, although toward the end of our mtg, patient
did manage a smile when he made a socially appropriate joke.
Thought process: Generally goal-directed, although
circumstantial at times, always able to come back to topic and
answer question w/o need for redirection. Perseverates on small
needs until they are addressed.
Thought content: no evidence of delusion, paranoia, grandiosity
apparent in our meeting today. Denies suicidal or homicidal
ideation. Denies abnl perceptions.
Insight/Judgment: Patient understands his medical situation and
hospital course. He shows an ability to consider choices and
make reasoned decisions with regard to his treatment based on
the
information he has available to him.
Impulse Control: Good
.
COGNITIVE STATUS EXAM:
Alert and oriented to full name, "Rm 1107 in the [**Hospital Ward Name 121**] [**Hospital1 107**]
building on the [**Hospital Ward Name 517**] of [**Hospital3 **] in [**Location (un) 86**]." He
thinks
it is [**12-2**] or 5 [**2186**] but has been unable to turn his head
to see the calendar.
He completed Days of week backwards perfectly and [**Doctor Last Name 1841**] backwards
with one inversion.
Visuospatial: He draws a neat, legible clock with correct time.
He can named 8 presidents until interrupted. He correctly
identifies 5 objects, remembers 3 objects at 5 minutes and
follows 3 step commands.
.
ROS: Gen: no F/C, fatigue or weight loss
HEENT- no oral ulcers, bleeding gums, hearing loss, sinus pain
or
sore throat
Cardiac- no CP, palpitations orthopnea or PND
Resp: chronic cough
GI- no anorexia, N/V, ABD pain
GU: no dysuria, hematuria, frequency or urgency
MSK: c/o nerve pain in back and down B arms
Neuro: no numbness, weakness dizziness, vertigo, H/A or mental
status changes
Skin- Decubitus ulcer / granulating
.
PE- 98.5 120/80 94 16 100% RA
Gen- well developed male in NAD
HEENT- no cervical, supraclavicular or axillary LAD
CVS- RRR No M/R/G
Lungs- Distant BS bilaterally. No wheezes or rhonchi appreciated
ABD- NABS, soft, NTND
Ext- Warm. RLE with chronic venous stasis changes.
Pertinent Results:
[**2186-12-6**] 08:40AM BLOOD
WBC-4.7 RBC-3.68* Hgb-11.9* Hct-33.6* MCV-91 MCH-32.3*
MCHC-35.4* RDW-17.5* Plt Ct-245
[**2186-11-30**] 04:53AM BLOOD
PT-13.6* PTT-26.3 INR(PT)-1.2*
[**2186-12-8**] 05:25AM BLOOD
Glucose-105 UreaN-7 Creat-0.4* Na-137 K-4.0 Cl-101 HCO3-28
AnGap-12
[**2186-12-8**] 05:25AM BLOOD
Calcium-8.2* Phos-5.5* Mg-1.4*
[**2186-11-8**] 01:50PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-0
[**2186-12-10**] 10:00 am SWAB Source: buttock.
GRAM STAIN (Final [**2186-12-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. CONSISTENT
WITH PROPIONIBACTERIUM SPECIES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS.
AND IN CLUSTERS.
WOUND CULTURE (Final [**2186-12-13**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
CT T-SPINE W/O CONTRAST [**2186-12-7**] 3:53 PM
Reason: Please do CT T-spine and L-spine. Lung mass, please
assess f
CT of the thoracic spine without contrast dated [**2186-12-7**].
HISTORY: 49-year-old homeless male with extensive vascular
disease and known lung mass; assess for thoracic vertebral
metastases.
FINDINGS: Study is compared with recent plain radiographs dated
[**2186-11-24**]. There is no paravertebral soft tissue abnormality. No
lytic or sclerotic bone destructive lesion is appreciated. There
are multilevel Schmorl nodes, particularly in lower thoracic
vertebral superior end plates. There is anterior wedge deformity
of the L1 vertebral body, likely chronic, which appears
associated with a prominent Schmorl node in the anterior aspect
of its inferior end plate. There is a low thoracolumbar
dextroscoliosis.
Noted is an irregular spiculated nodular opacity in the left
upper lobe, incompletely imaged, likely corresponding to the
known FDG-avid mass. Also noted is extensive atherosclerotic
change involving the thoracic aorta.
IMPRESSION:
1) No bony destructive lesion identified in the thoracic spine.
2) Chronic- appearing wedge deformity of the L1 vertebral body,
which may relate to prominent Schmorl node in its inferior end
plate (see separate report of lumbar CT study).
3) Irregular spiculated nodule in the left upper lobe,
corresponding to the known lung mass.
Pathology Examination
SPECIMEN SUBMITTED: 4R, 4L LOWER PARA TRACHEAL NODES, 2R, 2L
UPPER PARA TRACHEAL NODES AND SUBCRANIAL (5)
DIAGNOSIS:
1. 4R lower paratracheal nodes (A-B):
Thirteen (13) lymph node fragments, all with no evidence of
malignancy.
2. 2R upper paratracheal nodes (C):
Two(2) lymph node fragments, both with no evidence of
malignancy.
3. 4L lower paratracheal nodes (D):
Six (6) lymph node fragments, all with no evidence of
malignancy.
4. 2L upper paratracheal nodes (E):
Three (3) lymph node fragments, all with no evidence of
malignancy.
5. 7 subcarinal nodes (F-H):
Nine (9) lymph node fragments, all with no evidence of
malignancy.
Clinical: Not indicated.
Gross: The specimen is received in five parts all labeled with
the patient's name, "[**Known lastname 6203**], [**Known firstname **]" and with the medical
record number.
Part 1 is additionally labeled "4R lower para tracheal nodes"
and consists of multiple fragments of pink- tan anthracotic
lymph nodes measuring up to 2.0 x 0.5 x 0.2 cm entirely
submitted in cassettes A-B.
Part 2 is additionally labeled "2R upper para tracheal nodes"
and consists of two fragments of pink-tan tissue measuring up to
0.9 x 0.5 x 0.2 cm. These specimen are bisected and entirely
submitted in cassette C.
Part 3 is additionally labeled "4R lower para tracheal lymph
nodes" and consists of multiple fragments of pink-tan and
anthracotic lymph nodes measuring up to 1.5 x 0.5 and the
specimen is entirely submitted in cassette D.
Part 4 is additionally labeled "2L upper para tracheal lymph
nodes" and consists of multiple fragments of pink-tan and
anthracotic appearing lymph nodes which measure up to 1.0 x 0.5
x 0.3 cm entirely submitted in cassette E.
Part 5 is additionally labeled "7 subcarinal nodes" and consists
of multiple fragments of pink-tan and anthracotic appearing
lymph nodes measuring up to 4.0 x 1.0 x 0.5 cm entirely
submitted in cassette F-H.
Cardiology Report STRESS Study Date of [**2186-10-25**]
EXERCISE RESULTS
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 54
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: This 49 yo diabetic male was referred to the lab
for
evaluation prior to surgery. The patient was infused with 0.142
mg/kg/min of IV Persantine over 4 minutes. The patient denied
any arm,
neck, back or chest discomfort throughout the study. There were
no
significant ST segment changes noted. The rhythm was sinus with
occas.
APB's & VPB's. There was an appropriate blood pressure response.
IMPRESSION: No anginal symptoms or ischemic EKG changes noted.
Nuclear
report sent separately.
Cardiology Report ECHO Study Date of [**2186-10-10**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.41 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - E Wave Deceleration Time: 155 msec
Pulmonic Valve - Peak Velocity: 0.9 m/sec (nl <= 1.0 m/s)
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
GENERAL COMMENTS: Left pleural effusion.
Conclusions:
1. 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
difficult to assess but is probably normal.
[**2186-10-20**]
FDG TUMOR IMAGING (PET-CT)
METHODS: Approximately 1 hour after intravenous administration
of F-18
fluorodeoxyglucose (FDG), noncontrast CT images were obtained
for attenuation correction and for fusion with emission PET
images. [The noncontrast CT imagesare not used to diagnose
disease independently of the PET images.] A series ofoverlapping
emission PET images was then obtained. The fasting blood
glucoselevel, measured by glucometer before injection of FDG,
was 87 mg/dL. The areaimaged spanned the region from the skull
base to the proximal thighs.
Computed tomography (CT) images were co-registered and fused
with emission PETimages to assist with the anatomic localization
of tracer uptake. The
determination of the site of tracer uptake seen on PET data can
have importantimplications regarding the significance of that
uptake.
INTERPRETATION:
There is focal abnormal uptake of FDG in a left upper lobe
spiculated nodule (SUVmax 3.1) and mild FDG-uptake in a more
lateral spiculatednodule (SUVmax 1.7).
There is mild uptake in paraesophageal region at the
azygoesophageal recess,where there is a tubular hyperdense
structure; it is probably vascular.
There are bilateral pleural effusions and on the right at the
level of the rightmain pulmonary artery there is an FDG-avid
area where the lung is compressed wwith an SUVmax 5.0.
There is an FDG-avid right iliac node (SUVmax 4.2).
Physiologic uptake is seen in the brain, heart GI and GU tracts.
There is a right maxillary sinus retention cyst, bullae in the
lungs and a
non-FDG-avid cyst in the tail of the pancreas.
IMPRESSION:
1. FDG-avid spiculated nodule in the left upper lobe concerning
for
lung cancer.
2. On the right at the level of the right main pulmonary artery
there is an FDG-avid focus (SUVmax = 5.0) where the lung is
compressed by pleural effusion without a distinct anatomical
correlate. 3. Right FDG-avid iliac node likely reactive
Brief Hospital Course:
This patient was admitted to [**Hospital1 18**] on the Vascular Surgery
service for bilateral lower limb ischemia (transfer from
[**Hospital 69040**] Hospital). Below are his major hospital events. The
patient, after having his 2 procedure completed, underwent
extensive screening for a rehabilitation center.
.
- [**10-4**]: Plastics consult for sharps debridement to left gluteal
.
- [**10-5**]: Bilateral common iliac artery stent placement, right
external iliac artery stent placement, bilateral common femoral
arterial cutdown with primary repair.
.
- [**10-20**] PET: 1. FDG-avid spiculated nodule in the left upper lobe
concerning for
lung cancer. 2. On the right at the level of the right main
pulmonary artery
there is an FDG-avid focus (SUVmax = 5.0) where the lung is
compressed by
pleural effusion without a distinct anatomical correlate. 3.
Right FDG-avid
iliac node likely reactive.
.
- [**10-25**] Spirometry: There is a mild obstructive ventilatory
defect. There are no prior studies available for comparison.
.
- [**11-2**]: Cardiopulm stress testing results: Testing showed a
reduction in exercise capacity with a maximum oxygen consumption
of 25% of predicted (8.4 ml/kg/min) in a test terminated for
patient SOB and arm fatigue. Testing was performed using arm
ergometry and a maximum workload of approximately 35 [**Doctor Last Name **] was
attained during 6 minutes and 30 seconds of exercise. There was
an adequate exercise test effort as indicated by the Rq of 1.10
at peak exercise. There was no pulmonary mechanical limitation.
The elevated Ve/VCO2 and reduced DLCO from prior testing are
consistent with pulmonary vascular disease, however the lack of
desaturation indicates that this is not a primary factor in the
patient?s exercise limitation. Please note that the maximum
normal gas exchange values for arm ergometry are not well
characterized, but are likely on the order of 50% of those
obtained via treadmill.
.
- [**11-3**]: Cervical mediastinoscopy, flexible bronchoscopy.
Results: 1. 4R lower paratracheal nodes (A-B): Thirteen (13)
lymph node fragments, all with no evidence of malignancy.2. 2R
upper paratracheal nodes (C):Two(2) lymph node fragments, both
with no evidence of malignancy.3. 4L lower paratracheal nodes
(D):Six (6) lymph node fragments, all with no evidence of
malignancy.4. 2L upper paratracheal nodes (E): Three (3) lymph
node fragments, all with no evidence of malignancy.5. 7
subcarinal nodes (F-H): Nine (9) lymph node fragments, all with
no evidence of malignancy.
.
- [**11-24**]: T spine films done - No listhesis or fracture.
.
- [**12-1**]: Seen by psych with the following asessment -
Axis I: R/O psychosis NOS based on history
R/O alcohol abuse, in forced remission
Axis II: R/O schizotypal personality disorder
Axis III: lower extremity ischemia, multiple ulcers
AXIS IV: homeless, socially isolated
RECOMMENDATIONS:
At this point, patient is agreeable to discharge to a supported
care facility, stating that he recognizes he needs help and
cannot care for himself w/o some assistance. If he vacillates
in his decision, that would be a reason to re-explore
the question of capacity as expression of choice over time is a
component of capacity. His main concern is his car, which is,
in essence, his home. He is worried that he will lose his car
if he goes somewhere that does not allow him to keep up with the
insurance payments. Social work notes indicate that his car is
still at the rest area on Rt. 24 and the state troopers are
aware that he will retreive it when he can.
This conversation will likely be difficult given his
preoccupation with his pain. A helpful lead in might be to say,
"I understand that you are worried about your
pain and we want to help you feel as good as you can. This is
what we know is going on right now... " to explain the results
of tests, more concrete recommendations for disposition and a
timeline for disposition (patient is worried that he will be
sent
to the street in pain and unprepared).
Continue adequate pain management. It may be helpful to put
patient on an ATC regimen of pain meds rather than prn, as he
appears very worried that somehow his need for pain mgmt will be
overlooked.
.
- CT SCAN for continued baclk pain:
IMPRESSION:
1) No bony destructive lesion identified in the thoracic spine.
2) Chronic- appearing wedge deformity of the L1 vertebral body,
which may relate to prominent Schmorl node in its inferior end
plate (see separate report of lumbar CT study).
3) Irregular spiculated nodule in the left upper lobe,
corresponding to the known lung mass
.
- [**2186-12-8**]: Wound Care - WOUND CARE - gluteal ulcer.
.
The right gluteal ulcer continues to heal nicely measuring today
at 8.5 x 4.5cm. The wound base remains beefy red granulation
tissue 100%. There is moderate amounts of drainage,
nonmalodorous. The edges are fresh new epithelial and flat. The
periwound tissue is intact.
Pt remains on a 1st step low air loss mattress and is having
back pain and spasms. Back pain may be worsened by the 1st step
mattress and pt may benefit from regular mattress since he is
able to turn independently and keep off his gluteal.
Suggest: Continue with Allevyn foam dressings q 2 -3 days.
.
- OTHER: Patients extended hospital stay due to insurance
issue's,, homelessness
Medications on Admission:
Neurontin, quetiapine, metoprolol,
simvastatin, asa, protonix, dilauded prn, folic acid, thiamine,
RISS, dilaudid prn
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
13. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
14. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once
a day (at bedtime)).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day: prn.
16. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
1) B/L iliac stenosis
2) Pulmonary nodules
3) lung ca
4) decubitis ulcers
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-3**]
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
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-1**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Call Dr.[**Name (NI) 2347**]/Thoracic Surgery office for appointment
in 2 weeks. [**Telephone/Fax (1) 170**].
Call Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 8082**]. He is associated
with Radiology Oncology. Appointment for 2 weeks.
You have a visit with Dr. [**Last Name (STitle) **] on [**1-16**] at 930am. Do not eat
or drink anything for 6 hours prior to office visit as you are
having an ultrasound. Phone [**Telephone/Fax (1) 1241**]
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **].([**Telephone/Fax (1) 5562**] E/[**Hospital Ward Name 23**]- Hematology/O
[**Hospital1 18**]. Make an appointment in 2 weeks
Completed by:[**2186-12-13**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,253
| 197,961
|
14348+56530+56531+56532+56579
|
Discharge summary
|
report+addendum+addendum+addendum+addendum
|
Admission Date: [**2182-7-8**] Discharge Date:
Date of Birth: [**2119-8-30**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 52-year-old woman
with COPD on chronic p.o.steroids, CHF, CAD, diabetes type 2,
transferred from the outside hospital MICU for further
treatment of C.difficile colitis. The patient was initially
admitted for shortness of breath, COPD flare and found to
have left lower lobe pneumonia treated with broad-spectrum
antibiotics. The patient was discontinued to rehabilitation,
but then bounced back with shortness of breath. One week
prior to transfer, the patient began to have abdominal pain
and diarrhea, increasing distention. CT scan showed
pancolitis. Stool culture at that time was felt to be
positive C.difficile reportedly, but later found out that
this had not been done. The patient was started on p.o.
Flagyl. Over the weekend the patient was felt to have
worsening abdominal examination. Surgical consultation felt
that she had increased risk and declined intervention. Also,
notable for cardiac enzymes leaks, treated with aspirin, beta
blocker, and Lovenox. The patient was transferred to [**Hospital1 1444**] for further evaluation and
management. Upon arrival, vital signs were stable. The
patient was in obvious discomfort. The patient had
complaints of diffuse body pain.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease
2. Congestive heart failure.
3. Coronary artery disease.
4. Diabetes mellitus type 2.
5. Depression.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER:
1. ....................
2. Flagyl 500 p.o.t.i.d.
3. Ciprofloxacin 400 b.i.d.
4. Fluconazole 100 IV q.d.
5. Serevent 2 puffs b.i.d.
6. Pulmicort 2 puffs b.i.d.
7. Cardizem CD 180 q.d.
8. Prednisone 20 b.i.d.
HOME MEDICATIONS: Lasix 40 q.d.; Singular 10 q.d.; Paxil 20
q.d.; aspirin 81; Imdur 60 b.i.d.; [**Last Name (un) **]-Dur 300 b.i.d.;
Fosamax 10 q.d.; Celebrex 100 times four; Reglan 10 q.a.m.;
q.p.m.; Prednisone 20 b.i.d.; Insulin 24 q.a.m. 14 q.p.m.
PHYSICAL EXAMINATION: GENERAL: This is an obese, elderly
woman laying in bed in mild distress. HEENT: Oropharynx
clear without lymphadenopathy. Extraocular muscles are
intact. Cor: Regular rate and rhythm, no murmurs.
PULMONARY: No wheeze, clear to auscultation bilaterally.
ABDOMEN: Obese, tender to palpation diffusely, tympanetic,
diffusely ecchymotic. RECTAL: Guaiac negative. Formed
stool in vault. EXTREMITIES: There was 1+ pitting edema
bilaterally of extremities.
LABORATORY DATA: Laboratory data revealed the following:
White count 7, hematocrit 35.2, platelet count 239,000,
sodium 134, potassium 3.4, chloride 99, bicarbonate 27, BUN
14, creatinine 0.2, glucose 168, calcium 6.4, ionized .97,
phosphorus 1.8, magnesium 1.6, ABG 7.42, 44, 71, ALT 24, AST
20, alkaline phosphatase 78, amylase 4, lipase 7, total
bilirubin .3, albumin 1.9. Outside data, [**6-22**] sputum 3+
[**Female First Name (un) 564**], 2 normal flora; [**6-17**], 3+ Actineobacter.
IMAGING: [**7-6**] CT of the abdomen at outside hospital revealed
diffuse thickening of the colonic wall consistent with
pseudomembranous colitis, relative opacity in the upper pole
of the left kidney question tumors; [**7-4**] KUB prominent
markings, increased gas, question colitis; [**7-2**] chest CT
revealed bilateral upper lobe emphysema with bullous changes,
no pneumonia or effusion, lingular infiltrate.
Chest x-ray on admission: Consolidation of both lower lobes,
which may be consistent with pneumonia or aspiration.
ABDOMEN: Not included. Gases present through slightly
dilated colon, but no evidence of toxic megacolon.
HOSPITAL COURSE: The patient was admitted to the ICU. CT
scan on the following day showed atelectasis, right lung
base, free fluid in the abdomen, surrounding liver and
spleen, fluid within the right lateral soft tissues measuring
than 10 haustral units and not felt consistent with
hemorrhage. Distention of large bowel without
intra-abdominal air. No air within the bowel wall. There
was concern about the fluid tracking into the soft tissue.
It was attempted to be aspirated under ultrasound guidance
and 2 cc of fluid were aspirated, but no large fluid
collection. That fluid was gram-stain negative and,
therefore, grew. The patient was made NPO, IV fluids,
started on p.o. Vancomycin and Flagyl. KUBs were followed
serially throughout the ICU course. The Gastrointestinal
Department was consulted. The Department of Surgery was also
consulted, followed and felt that the patient did not need
surgical intervention at that time. The Flagyl was then
changed to IV. Rectal tube and frequent turning were
initiated, however, the patient had no stool output. The
patient was started on TPN for nutrition. From a pulmonary
standpoint, nebs and MDI were continued. Prednisone was
being tapered. The patient had transient hyponatremia to
129, thought secondary to quick mix and not resolved. Few
episodes of decreased urine output, which was treated with IV
fluids and resolved on [**7-12**]. The patient was noted to have
nine bands up from three on [**7-11**] and down from 41 on admission
on [**7-8**]. On [**7-13**], the patient was felt stable for transfer to
the medical floor. On that day it was noted that the left
upper extremity was larger than the right and there was
concern for clot. Ultrasound was done, which was negative
for DVT.
HOSPITAL COURSE: (by system)
GASTROINTESTINAL: The patient's abdominal examination was
followed serially. Gastrointestinal Department and Surgery
Department continued to follow the patient. KUBs were done
serially to assess the amount of distention.
On [**7-14**] CT of the abdomen was repeated, which showed no
evidence of abscess formation or microperforation. There was
no interval change in the colonic distention or mild
thickening in the sigmoid. There was a slight interval
increase in the dilatation of the small bowel loops with
multiple air-fluid levels consistent with ileus. Stable
amount of free fluid. Interval increase in regional
interstitial nodular opacification of the left lower lobe
which might have been a developing pneumonia. Given the
patient's discomfort nasogastric tube was placed and a large
amount bilious fluid was returned. The NG tube was continued
for decompression. The patient was followed by the
Gastrointestinal Department and Surgery Department. The
Gastrointestinal Department was considering doing a flexible
sigmoidoscopy given that we had no diagnosis. All C.
difficile cultures sent were negative and there were no
outside cultures that were positive. The patient had several
lactates done for concern of ischemic bowel, however,
lactates were all within normal range. On the day of planned
sigmoidoscopy on [**7-17**], the patient required transferred to
the ICU. Please see below. Therefore, it was deferred.
During the ICU stay the abdominal examination slowly improved
and the Department of Surgery signed off.
The patient completed a full course of Flagyl and Vancomycin
for presumed C. difficile colitis. She was started on clears
and she was tolerating clears. Diet was slowly advanced. On
[**7-24**] flexible sigmoidoscopy was performed. This showed
ulceration, granularity, and friability, erythema and
pseudomembranes in the colon concerning for C-difficile
colitis versus ischemic colitis, biopsy taken, sent stat and
pending at this time. The patient was also continued on
Protonix.
INFECTIOUS DISEASE: The patient completed a full course of
Flagyl and Vancomycin for presumed C. difficile colitis. The
patient remained afebrile throughout the hospitalization,
however, this was felt possibly related her steroids and that
she was immunocompromised.
White count was monitored and it was noted that the patient
was having increasing bandemia. ON [**7-14**] blood cultures were
drawn and these were found to be positive for Staph coagulase
negative. The Infectious Disease Department was also
consulted and followed the patient. She was treated with IV
Vancomycin for this. Catheter tip from the central line was
culture. The central line was removed on [**7-15**] and this was
positive for Staphylococcus coagulase negative. It was felt
this was the source of her bacteremia. The patient continued
to have positive blood cultures on the 11th and 12th.
Therefore, she was to be continued on an extended 14 day
course of Vancomycin. Additionally, there was concern that
this could be an endovascular source, given the high-grade
bacteremia. Transthoracic echocardiogram was performed on
[**7-16**], which showed LA and LV thickness, normal size, LV
function could not be assessed. Aortic root mildly dilated,
mild pulmonary artery systolic hypertension, no evidence of
endocarditis.
On [**7-17**], the patient developed chest pain without EKG
changes. The hematocrit dropped with unclear etiology and
given her high-grade bacteremia, she was transferred back to
the ICU for closer monitoring.
On the 14th transesophageal echocardiogram was done, which
showed no evidence of endocarditis. The patient had a left
subclavian line put back in on [**7-16**] given her peripheral
access was difficult. The patient completed a course of IV
Fluconazole and this stopped. It was started for UTI,
thrush, and also bowel coverage given her distention.
On transfer to the ICU repeat CT scan of the abdomen was
done. Findings were consistent with incomplete small-bowel
obstruction, transitional zone distal ileum, oral contrast in
the terminal ileum, large bowel unchanged fluid in the
peritoneal cavity, slight increase in right pleural effusion,
atelectasis in left lower lobe, consolidation in the left
lower lobe. Therefore, the patient was started on Levaquin
to cover the pneumonia for a ten day course.
PULMONARY: On admission, Prednisone was tapered given her
infection. It was tapered to 20 q.day. However, it was
noted that when the patient started stooling, occult
fragments were seen and there was concern for her absorption.
She was changed to Solu-Medrol IV. She was continued on
nebulizer treatments followed by RT, MDIs and oxygen p.r.n.
The patient continued to be bronchospastic intermittently and
Solu-Medrol dose was increased. The patient was noted to
improve significantly for one day and she was changed to
p.o.Prednisone the following day. She again was noted to be
more bronchospastic and she complained more of shortness of
breath. Therefore, given the concern that she was not
absorbing the medications from her gastrointestinal tract she
was switched back to IV Solu-Medrol at 20 b.i.d.
RENAL: During the first stay in the ICU, she had some
decreased urine output, however, this was thought to be
intravascular depletion and this resolver her creatinine and
the BUN remained stable. During the second ICU stay from
[**7-17**] to [**7-21**] diuresis with Lasix was initiated given the
patient's anasarca, which was thought secondary to her low
albumin. However, it was noted that the bicarbonate rose
after diuresis and it was felt that she had a contraction
alkalosis, so diuresis as was then held. Alkalosis began
developing.
HEMATOLOGY: The hematocrit was noted to drop from stable in
the low 30s to 25 on the 12th. It was repeated and found to
be 27, but on the 13th it was 4.1, unclear etiology, as the
patient was guaiac negative. Reticulocyte count was noted to
be 4.4, haptoglobin 201, LDH was elevated, total bilirubin
was not, and they felt that the LDH was not secondary to
hemolysis. No source was found. The patient was transferred
two units of packed red blood cells and the hematocrit
stabilized. It was also noted on [**7-13**] that the platelets
started to fall. On [**7-14**] they were noted to be 113. DIC
panel was sent and it was negative. HIT antibody was
negative. Platelets then rebounded within normal limits.
On [**7-23**], the patient again had a hematocrit drop from the day
before 37.7 to 31.9, however, it was stabler and monitored.
After that, hemolysis labs at that time were also negative.
CARDIOVASCULAR: At the outside hospital the patient had a
mild troponin leak of 0.6 with CKs all less than 100. During
the hospitalization here she was continued on aspirin and
Cardizem.
On the 12th, when she developed chest pain, EKG was
unchanged. She was rule out by cardiac enzymes for MI.
Blood pressure was monitored and it was within reasonable
control.
EDEMA: The patient at one point had been thought to have
left upper extremity edema greater than right, however, upper
extremity ultrasound was done and this was negative.
Additionally, on the 17th, it was felt that she had increased
left lower extremity edema and tenderness. Ultrasound was
done and it was negative for DVT. It was felt that patient's
edema was secondary to IV fluids and nutritional status.
PAIN: The patient had various muscular complaints in her
legs and arms. CK was sent to look for myositis and it was
negative at 29. It was felt likely that this was secondary
to being in bed and anasarca. The patient was treated with
Ultram which helped.
ENDOCRINE: The patient's fingersticks were monitored. TPN
insulin was increased, as well as she was followed with a
regular insulin sliding scale. She was continued on
Prednisone as above.
FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
continued on TPN for nutrition. The Department of Nutrition
followed the patient. Electrolytes were repleted as needed.
PROPHYLAXIS: The patient had heparin and in her TPN. When
the heparin was stopped briefly and withdrawn she was
maintained on Pneumoboots. She was continued on Protonix.
PT and OT worked with the patient.
Addendum will be added to the complete hospital course.
Dictated By:[**Last Name (NamePattern1) 4572**]
MEDQUIST36
D: [**2182-7-25**] 14:07
T: [**2182-7-25**] 14:17
JOB#: [**Job Number 42559**]
Name: [**Known lastname 7694**], [**Known firstname **] Unit No: [**Numeric Identifier 7695**]
Admission Date: [**2182-7-8**] Discharge Date:
Date of Birth: [**2119-8-30**] Sex: F
Service:
ADDENDUM: Patient's C. diff colitis has continued to respond
to Vancomycin treatment. She complains of some bloating
which is improving with medical care. Her COPD is improving.
She is maintaining 94% saturation on three liters of oxygen
and is subjectively less short of breath. She remains on TPN
due to limited po intake secondary to shortness of breath
while eating. However, her po intake is improving and when
her TPN is discontinued, she will require subcutaneous NPH
insulin as well as subcutaneous Heparin which are currently
included in her TPN.
On physical exam [**First Name8 (NamePattern2) 1693**] [**Known lastname **] is an obese female in no
apparent distress. Lung exam reveals coarse rhonchi
bilaterally with an extended expiratory phase. Cardiac exam
shows regular rhythm with no murmurs. Abdominal exam has
positive bowel sounds, nontender, distended, soft. Her
sacral decubitus shows a well healed ulcer and over the last
three days she has self diuresed three liters of fluid which
has also helped improve her breathing. [**First Name8 (NamePattern2) 1693**] [**Known lastname **] is being
discharged to rehabilitation at [**Hospital1 **] on [**7-29**] in stable
condition.
DISCHARGE DIAGNOSIS:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease.
3. Congestive heart failure.
4. Diabetes.
5. Depression.
DISCHARGE MEDICATIONS: Include Prednisone 20 mg po bid to be
tapered by her primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7696**]. Sliding
scale insulin, Serevent 2 puffs [**Hospital1 **], Flovent 110 mcg 2 puffs
[**Hospital1 **], Albuterol nebs prn q 4 hours, Atrovent MDI and nebs po q
4 hours, Protonix 40 mg po bid, Cardizem 180 mg po q day,
Nystatin swish and swallow 5 ml po qid, Nystatin powder to
groin q day, Tylenol prn, Ativan prn, Vancomycin 250 mg po
qid times 17 days, currently on TPN with 90 units of regular
insulin and 5,000 units of subcu Heparin, Clonazepam 0.25 mg
[**Hospital1 **], Ultram 50 mg q 8 hours prn, Imdur 60 mg po bid, Paxil 20
mg po q day, Singulair 10 mg po q day and Simethicone 80 mg
po q 6 hours prn.
FOLLOW-UP: [**First Name8 (NamePattern2) 1693**] [**Known lastname **] will follow-up with her primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7696**] [**Telephone/Fax (1) 7697**] and requires a CT in
four weeks. When her TPN is discontinued, she will require
NPH insulin and subcu Heparin.
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**]
Dictated By:[**Last Name (NamePattern1) 7698**]
MEDQUIST36
D: [**2182-7-29**] 12:41
T: [**2182-7-29**] 12:53
JOB#: [**Job Number 7699**]
Name: [**Known lastname 7694**], [**Known firstname **] Unit No: [**Numeric Identifier 7695**]
Admission Date: [**2182-7-8**] Discharge Date: [**2182-7-29**]
Date of Birth: [**2119-8-30**] Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM: This addendum covers dates [**2182-7-28**] until [**2182-7-29**]. During this time Ms. [**Known lastname **]'
COPD has continued to improve and response to her medical
therapy. She is feeling less short of breath and less bloated
and is now able to increase po intake. Her COPD is also
improving with therapy. She is feeling subjectively less
short of breath. Her O2 saturations has been 94% on three
liters of oxygen and she is also increasing her po intake as
her COPD improves and as her bloating resolves. Require TPN
until she is tolerating full po. When she does convert to
full po and TPN is discontinued she will require NPH insulin
as she is receiving regular insulin in her TPN. She will also
require subcutaneous Heparin at that time as well.
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**]
Dictated By:[**Last Name (NamePattern1) 7700**]
MEDQUIST36
D: [**2182-7-29**] 12:17
T: [**2182-8-2**] 08:09
JOB#: [**Job Number 7701**]
Name: [**Known lastname 7694**], [**Known firstname **] Unit No: [**Numeric Identifier 7695**]
Admission Date: [**2182-7-8**] Discharge Date: [**2182-7-29**]
Date of Birth: [**2119-8-30**] Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM: Mrs. [**Known lastname **]' C difficile colitis
is improving in response to her Vancomycin therapy. She is
continuing on TPN until she can tolerate full po. At that
time she will require NPH insulin injections subcutaneous as
well as subcutaneous Heparin. Most of these are currently in
her TPN bag.
On physical examination Ms. [**Known lastname **] has bilateral rales with
extended expiratory phase. Cardiac - she has a regular rhythm
with no murmurs. Abdomen is soft, nontender, distended and
tympanitic with positive bowel sounds.
She is being discharged to [**Hospital **] Rehabilitation in stable
condition.
DISCHARGE DIAGNOSIS:
1. C difficile colitis.
2. COPD.
3. CAD.
4. CHF.
5. Depression.
6. Right sacral decubitus ulcer.
MEDICATIONS:
1. Tylenol 325 mg po q four hours prn.
2. Protonix 40 mg po bid.
3. Clonazepam 25 mg po bid.
4. Atrovent metered dose inhaler with spacer two puffs [**Hospital1 **].
5. Serevent inhaler two puffs [**Hospital1 **].
6. Flovent 110 micrograms two puffs [**Hospital1 **].
7. Nystatin swish and swallow 5 ml po qid.
8. Nystatin powder to groin tid.
9. Albuterol and Atrovent nebs q four hours prn.
10. Ultram 50 mg po q eight hours prn.
11. Vancomycin 250 mg po qid times three weeks.
12. Cardizem 180 mg po q day.
13. Prednisone 20 mg po bid. Primary care physician to taper
as tolerated.
14. Singular 10 mg po q day.
15. Paxil 20 mg po q day.
16. Imdur 60 mg po bid.
As noted previously the patient is receiving regular insulin
in her TPN as well as Heparin in her TPN. When TPN is
discontinued she will require Heparin 5000 units subcutaneous
[**Hospital1 **] as well as NPH insulin.
The patient requires wound care for her right sacral
decubitus ulcer. She also requires PIC care. Ms. [**Known lastname **] will
need a CT scan in four weeks with her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 7696**], [**Telephone/Fax (1) 7697**].
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**]
Dictated By:[**Last Name (NamePattern1) 7700**]
MEDQUIST36
D: [**2182-7-29**] 12:30
T: [**2182-8-2**] 08:15
JOB#: [**Job Number 7702**]
Name: [**Known lastname 7694**], [**Known firstname **] Unit No: [**Numeric Identifier 7695**]
Admission Date: Discharge Date:
Date of Birth: Sex: F
Service:
ADDENDUM: On [**7-25**] biopsy from flexible sigmoidoscopy
showed evidence consistent with Clostridium difficile
colitis, therefore the patient was started on p.o. Vancomycin
125 mg p.o. q.i.d. for three weeks. She should follow up
with her primary care physician in four weeks for a
computerized tomography scan. If all abnormalities are not
resolved, she needs to follow up with Gastroenterology after
that. A PICC line was successfully placed and therefore her
left subclavian line was discontinued. She was started on
clears and encouraged to take p.o. [**2182-7-26**] was the
last day of her Levaquin for her pneumonia and it was then
discontinued after her dose. The patient was then continued
on total parenteral nutrition, however, when she is taking
good p.o. her total parenteral nutrition will be stopped. At
that time the patient will need to receive subcutaneous
insulin NPH as she is receiving insulin and her total
parenteral nutrition. Additionally she will need
subcutaneous heparin for deep vein thrombosis prophylaxis.
She is currently receiving heparin and her total parenteral
nutrition and that will be discontinued when the total
parenteral nutrition is discontinued.
Please see summary addendum added to this with accurate
medications on discharge.
DISCHARGE DIAGNOSIS:
1. Clostridium difficile colitis
2. Left lower lobe pneumonia
3. Chronic obstructive pulmonary disease
4. Coronary artery disease
5. Congestive heart failure
6. Decubitus ulcer
7. Depression
8. Edema
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D.
[**MD Number(1) 4338**]
Dictated By:[**Last Name (NamePattern1) 4693**]
MEDQUIST36
D: [**2182-7-26**] 15:37
T: [**2182-7-26**] 16:42
JOB#:
|
[
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"996.62",
"707.0",
"496",
"250.00",
"486",
"112.2",
"276.5",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"99.15",
"54.91",
"93.90",
"88.72"
] |
icd9pcs
|
[
[
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15570, 19094
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22202, 22651
|
5480, 15392
|
1841, 2076
|
2099, 3484
|
3499, 3697
|
1606, 1822
|
1379, 1581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,785
| 178,844
|
46488
|
Discharge summary
|
report
|
Admission Date: [**2167-5-27**] Discharge Date: [**2167-6-7**]
Date of Birth: [**2087-10-1**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
SOB, increasing edema
Major Surgical or Invasive Procedure:
S/P Angioplasty L leg
EGD
Colonoscopy
History of Present Illness:
79-year-old M with prior CABG in [**2161**] (LIMA - LAD, SVG - OM2),
hypertension, hyperlipidemia, diabetes mellitus, chronic kidney
disease, peripheral arterial disease and prior episodes of heart
failure presents from [**Year (4 digits) **] clinic with incareasing SOB and
worsening edema. Pt. feeling more SOB over last month but more
so over last week. His diuretic regimen, Torsemide was recently
increased from 50mg twice a day to 100mg in am; 50mg in pm. Pt.
taking off HCTZ due to bump in creat 3.4 but pt. restarted on
own at 12.5mg daily. Nonpitting thigh edema & in lower legs.
Weight 208 & dry weight usually <200 lbs. Pt describes no Chest
pain, palpitations. At baseline, pt on home O2 at bedtime for
several years now 5L NC. Pt has also noted increasing abdominal
girth, thigh edema and worsening DOE.
.
ED COURSE: Started lasix gtt 1ml/mg/hr off at 1800, received ASA
325mg X1, NTG 0.4mg x3, GI Cocktail, morphine 2mg IV x1
Past Medical History:
1. CVA: ([**2154**]) 3-4 days of slurred speech and right facial
droop without residual symptoms. s/p CEA (documented however
patient without memory of this procedure)
2. IDDM (retinopathy, nephropathy, neuropathy)
3. CAD s/p 2V-CABG [**2161**]
4. CHF d/t diastolic + CRI EF 40-45% ([**1-13**]) baseline weight 200
5. NSVT
6. HTN
7. Hyperlipidemia
8. PVD s/p R fem-[**Doctor Last Name **] ([**2154**]), R 2nd toe amputation, gangrene L
1st toe s/p amp ([**10-11**](?))
9. CRI (b/l around 2.9-3.1)
10. colon ca s/p hemicolectomy
11. h/o diverticulosis
12. h/o angioectasia in stomach w/UGIB [**3-/2161**] and again [**7-/2166**]
13. prostate ca (dx'd [**2150**]): s/p orchiectomy ([**2150**]), TURP ([**2153**])
& pelvic XRT ([**2155**]) with radiation 'proctopathy'.
14. iron deficiency anemia on bone marrow aspirate ([**2157**])
15. interstitial lung disease w/mediastinal LAD & a negative
CMA. (Differential diagnosis included burned out
sarcoidosis versus interstitial pulmonary fibrosis (IPF), versus
malignancy.) s/p flexible bronchoscopy and cervical
mediastinoscopy with biopsies ([**5-9**])
16. left cataract surgery
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: CABG, in [**2161**] anatomy as follows:
LIMA to LAD, SVG to major OM branch
.
Percutaneous coronary intervention, in [**3-8**] anatomy as follows:
1. Left main and one vessel severe coronary artery disease with
diffuse 3 vessel mild-moderate disease.
2. Normal right and left heart pressures.
.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient is widowed
and lives alone, but has assistance that comes into the home to
help around the house. He has VNA services once a week, and a
sister-in-law who assists with shopping. He is independent in
his ADLs. He is a retired foreman for [**Company 2676**]. He does have a
remote history of tobacco use, quit in his 20s. No history of
EtOH abuse or illicit drug use. At baseline, he gets short of
breath walking less than one block, and uses a walker.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - 96.0 BP 108/68 HR 80 RR 18 96%2L NC FS 131, WT 206.6
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 10 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: Bibasilar crackles, no wheezing or rhonchi.
Abd: Soft, distended, NT, +BS. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits. +Fluid wave.
Ext: 2+ thigh edema, toe amputations on L and R foot,
non-palpable DP pulses, cool R foot (at baseline)
Pertinent Results:
Unilateral LE veins left [**2167-5-27**]
LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale, color, and
pulse wave Doppler demonstrates the common femoral vein,
superficial femoral vein, and popliteal veins to demonstrate
normal flow with normal phasic respiratory variation. With the
exception of the distal superficial femoral vein, which was not
visualized well enough to compress, all other veins were
compressible. Note is made of multiple left inguinal lymph
nodes, the largest of which measures 2.3 x 0.7 x 1.2 cm, but
which demonstrate likely fatty hila, evidence of benignity.
IMPRESSION: No evidence of DVT in left lower extremity.
.
Art ext [**2167-5-29**]
IMPRESSION: Significant left tibial arterial disease.
Inability to identify Doppler signal in the left posterior
arterial level.\
COMPARISON: When compared to the exam performed on [**2164-12-27**],
there are no significant changes except for the fact that no
Doppler signal was identified in the left posterior tibial
arterial level.
.
Left foot xray: [**2167-5-29**]
IMPRESSION: No radiographic evidence for osteomyelitis. Status
post first digit amputation.
.
PERTINENT LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2167-6-6**] 06:35AM 6.1 4.30* 10.4* 34.6* 81* 24.1* 29.9*
18.2* 159
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2167-6-6**] 06:35AM 154* 72* 2.6* 149* 3.6 108 30 15
.
COAGS:
PT PTT Plt Ct INR(PT) [**Name (NI) 36549**]
[**2167-6-6**] 06:35AM 19.0* 31.1 1.8
.
Digoxin
[**2167-6-5**] 01:00AM 0.7
Brief Hospital Course:
79 year old male with past medical history of CAD s/p CABG,
congestive heart failure, diabetes, and chronic renal
insufficiency here with CHF exacerbation and left foot ulcer
.
Acute on Chronic systolic and diastolic heart failure: Patient
with low EF, and diastolic failure. He presented with SOB and
weight of 206 pounds from a dry weight <200 per recent clinic
notes. He has edema to knees with clear lungs. ACS as cause for
the exacerbation was ruled out with cardiac markers x3. THe
patient was diuresed with IV lasix 80mg [**Hospital1 **] for several days
with goal net negative 2L. Daily weights were taken and strict
i/o were monitored. Once he LE edema improved and weight
approached 200, his was switched back to his home dose of
torsemide 100mg qAM and 50mg qPM. He was continued on toprol XL
100mg [**Hospital1 **] and Digoxin 0.0625. Also of note patients oxygen
requirement improved with diuresis. Per patient, he is on 5L at
home; he required 1-2L after diuresis. Subsequent to the
vascular procedure c/b GIB, his diuretics were held. His home
torsemide was resumed prior to discharge.
.
Left Toe Ulcer/Claudication/PVD: Patient complaining of
claudication when walking and at rest. s/p 2 toe amputations.
Vascular was consulted. Pt's coumadin was held prior to going to
the OR, he was placed on a hep gtt with PTT goal 60-80 prior to
going to the OR. Vascular took pt to OR for angio on Tuesday per
results of NIAS: Significant left tibial arterial disease. He
underwent Left leg arteriogram and angioplasty with below-knee
popliteal anterior tibial arteries. His course was complicated
by a GIB in setting of his known GI AVMs.
.
GIB: Pt with known AVMs and known prior GIBs. Following
heparinization for the vascular procedure pt's PTT was
supratherapeutic, Hep was reversed with potamine. Pt
subsequently started to have BRBPR in addition to melena. Pt's
HCT also dropped. He was sent to the MICU for closer monitor. He
received 2 UPRBC while in the MICU, his HCT was stable at 34, he
had no further melena or hematochezia. Pt was instructed not to
resume coumadin per Dr. [**First Name (STitle) 437**], indefinately given high risk of
rebleeding. His ASA 81mg was resumed, tolerated well.
.
CAD: PAtient ruled out for ACS with cardiac enzymes negative x3.
s/p CABG. troponins at at baseline 0.18 and CKs are flat. ASA
325 mg, toprol 100BID, Simvastatin 10mg daily, however with GIB
as above his aspirin was initially held, his BB was held
initially but resumed and titrated up slowly. At time of
discharge his Aspirin was resumed at 81mg daily. Simvastatin was
continued.
.
Adjustment disorder: Patient with difficulty adjusting to
medical problems. Psychiatry consult appreciated and they
recommened psych VNA. PAtient also with trouble sleeping. They
recommended to avoid ambien, since patient confused with this
and also avoid trazadone. They recommend to use low dose remeron
for sleep when needed. social work consult also appreciated whom
recommended using social network, given involved family to help
with coping.
.
Atrial Fibrillation: diagnosed recently, rate controlled and on
coumadin. Continued toprol 100mg [**Hospital1 **], digoxin and coumadin 1mg
daily. As noted above, his coumadin was held prior to the OR,
given GIB no anticoagulation was resumed. His BB as noted above
also held but resumed and titrated to 75mg [**Hospital1 **]. His dig was
continued.
.
Diabetes Mellitus type II: Cont home regimen of lantus and
hemalog sliding scale.
- lantus 32 units q am, humalog per sliding scale, less
aggressive in PM. No ace-i given renal insufficiency. Diabetic
diet. His lantus was decreased to 16U qam due to some episodes
of hypoglycemia. This is to be retitrated up per PCP as an
outpatient. His FS were stable at time of discharge without
further episodes of hypoglycemia.
.
acute on chronic Renal insufficiency: Patient has long standing
renal insufficiency, with recent baseline around 3.0. [**Month (only) 116**] be
secondary to poor forward flow with CHF exacerbation, improved
with diuresis. Pt also received mucomyst 1200mg [**Hospital1 **] x2 days
prior to and subsequent to his angiography. He also received
bicarb prior to the procedure. At time of discharge his Cr was
at his baseline 2.6. Epo as outpatient
Calcitriol at home dosing.
.
History of stroke: given GIB his anticoagulation was held. ASA
was resumed.
.
Hyperlipidemia: Continued home dose of simvastatin.
.
Hypertension: Continuing home medications
.
Iron deficiency: Continuing iron
.
Anemia: HCT improved with 2UPRBC as noted above, receives epo on
outpatient basis.
.
Insomnia: behavioral, low dose remeron if needed, avoid ambien
and trazadone per psychatry
.
CODE: Spoke with pt at length who was very lucid at time of
conversation. He expressed his wish to be DNR/DNI. His son is
his HCP. [**Name (NI) **] pt, family is aware of his wishes and respect his
DNR/DNI status.
Medications on Admission:
-ASA 325mg qd
-calcitriol 0.25mcg qd
-coumadin 1mg qd
-digoxin 0.0625mg qd
-colace
-epo 2,000 u/ml per renal clinic,
-iron qd
-insulin lantus 32 units q am, humalog per sliding scale,
-mag 250mg qd,
-omeprazole 20mg [**Hospital1 **]
-kcl 10meq qd
-simvastatin 10mg qd
-toprol xl 200mg [**Hospital1 **]
-Torsemide 100mg in am;50mg in pm
-HCTZ 25mg as needed
-ambien 5mg prn
Discharge Medications:
1. Torsemide 100 mg Tablet Sig: One (1) Tablet PO each morning.
2. Torsemide 100 mg Tablet Sig: [**1-7**] Tablet PO each evening.
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: one half Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day): 75mg [**Hospital1 **].
Disp:*180 Tablet(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous qAM.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
-Acute on chronic systolic and diastolic CHF
-Ischemic L leg s/p angioplasty
-GIB from known AVMs
Secondary:
1. CVA: ([**2154**]) 3-4 days of slurred speech and right facial
droop without residual symptoms. s/p CEA (documented however
patient without memory of this procedure)
2. IDDM (retinopathy, nephropathy, neuropathy)
3. CAD s/p 2V-CABG [**2161**]
4. CHF d/t diastolic + CRI EF 50% ([**2-12**]) baseline weight 200
5. NSVT
6. HTN
7. Hyperlipidemia
8. PVD s/p R fem-[**Doctor Last Name **] ([**2154**]), R 2nd toe amputation, gangrene L
1st toe s/p amp ([**10-11**](?))
9. CRI (b/l 2.3-2.5)
10. colon ca s/p hemicolectomy
11. h/o diverticulosis
12. h/o angioectasia in stomach w/UGIB [**3-/2161**] and again [**7-/2166**]
13. prostate ca (dx'd [**2150**]): s/p orchiectomy ([**2150**]), TURP ([**2153**])
& pelvic XRT ([**2155**]) with radiation 'proctopathy'.
14. iron deficiency anemia on bone marrow aspirate ([**2157**])
15. interstitial lung disease w/mediastinal LAD & a negative
CMA. (Differential diagnosis included burned out
sarcoidosis versus interstitial pulmonary fibrosis (IPF), versus
malignancy.) s/p flexible bronchoscopy and cervical
mediastinoscopy with biopsies ([**5-9**])
16. left cataract surgery
[**76**]. Depression w/adjustment disorder
Discharge Condition:
Stable, no further bleeding, HCT stable
Discharge Instructions:
You were admitted with a CHF exacerbation. You were diuresed
with good effect. Your home diuretic was resumed at time of
discharge.
You must weigh yourself daily, call Dr. [**First Name (STitle) 437**] if your weight
increases by more than 3pounds. You must restrict your salt
intake and fluid intake to no more than 1.5 liters.
.
If you have chest pain, shortness of breath, palpitations,
lightheadedness, dizziness or bleeding from your rectum, black
stools call your physicians or go to the emergency room.
.
Your anticoagulation was held in the setting of bleeding.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2167-6-16**] 2:00
.
Please call Dr.[**Name (NI) 72943**] office tomorrow at [**Telephone/Fax (1) 18325**] to
schedule a follow up appointment in the next week.
Completed by:[**2167-6-8**]
|
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74,693
| 178,838
|
41897
|
Discharge summary
|
report
|
Admission Date: [**2199-3-8**] Discharge Date: [**2199-3-28**]
Date of Birth: [**2144-12-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Hypoglycemia, hypotension
Major Surgical or Invasive Procedure:
[**2199-3-19**];
1. Pancreatic necrosectomy.
2. Pseudocyst-gastrostomy.
History of Present Illness:
Mr. [**Known lastname 90960**] is a 54M with history of necrotizing pancreatitis c/b
pseudocyst formation who presents with weakness. Patient was
seen in clinic [**2199-3-8**] regarding operative planning for a cyst
gastrostomy. During this visit, he felt lightheaded and was
found to have a glucose of 30 and SBP in 80s. He was given juice
and felt some improvement, though not baseline. On admission
patient was
TPN dependent due to gastric obstruction from his pseudocyst.
[**First Name8 (NamePattern2) **] [**Last Name (un) **], his current TPN bag has the incorrect dose of
insulin (too high). Patient reports feeling well until this
episode. His weight has been stable. He has been drinking fluids
regularly with normal urine output. He denies nausea, vomiting,
and diarrhea. His abdominal pain is at his baseline. His blood
sugars at home have ranged from 40 to 200. Since coming to the
ED, he feels signifantly better, though he reports a headache.
Past Medical History:
1. Necrotizing pancreatitis complicated by acute fluid
collection and a small pseudocyst in the tail which gradually
disappeared over time. All this occurred in approximately [**2196**]
and his care has been at [**Hospital2 **] [**Hospital3 6783**] Hospital, [**State 17405**], and most recently [**Hospital6 **].
2. Prior celiac plexus block for pain control attempted [**4-/2197**]
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with no apparent benefit.
3. Status post ERCP in [**2196**] or [**2197**] by Dr. [**Doctor Last Name 90959**],
apparently notable only for mild biliary dilation and no sludge-
complicated by post ERCP pancreatitis according to patient
4. Status post cholecystectomy.
5. Hypertriglyceridemia.
6. Hypertension.
7. Multiple shoulder surgeries.
8. Fatty liver.
9. Schatzki's ring.
10. Gastritis.
Social History:
Currently on disability but former restaurant manager prior to
onset of pancreatitis in [**2196**]. Lives with his sister and mother
now since his wife passed away last year. Formerly very active
and has completed the [**Location (un) 86**] Marathon 4 times. Has remote
history of smoking, denies any alcohol use at this moment,
finished [**Hospital **] Rehab program.
Family History:
He has a familial history of hypertriglyceridemia. His sister
has MS. There is no family history of pancreatitis or
pancreatic cancers as far as he knows. No other family history
of GI or liver disease as far as he knows.
Physical Exam:
On Admission:
VS: 97.8 56 91/93 18 100%
Gen: Appears well, NAD
CV: RRR
Resp: CTAB
Abd: Soft, tender in epigastrium, mildly distended, ecchymosis
in
RLQ and at umbilicus (at sites of insulin injections per
patient), no rebound or guarding
Ext: Bilateral lower extremity edema
On Discharge:
VS: 98.2, 72, 116/70, 12, 100% RA
GEN: NAD
CV: RRR, no m/r/g
RESP: CTAB
ABD: Midline abdominal incision open to air with steri strips
and c/d/i. Old RLQ JP site with occlusive dressing and c/d/i.
Soft, NT/ND.
EXTR: Warm, no c/c/e
Pertinent Results:
[**2199-3-26**] 05:12AM BLOOD WBC-4.4 RBC-3.26* Hgb-9.3* Hct-27.4*
MCV-84 MCH-28.6 MCHC-34.0 RDW-14.3 Plt Ct-217
[**2199-3-27**] 04:00AM BLOOD Hct-29.5*
[**2199-3-26**] 05:12AM BLOOD Glucose-118* UreaN-8 Creat-0.7 Na-135
K-3.7 Cl-99 HCO3-29 AnGap-11
[**2199-3-26**] 05:12AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.6
[**2199-3-26**] 06:18PM ASCITES Amylase-9
[**2199-3-8**] 3:50 pm BLOOD CULTURE #2.
**FINAL REPORT [**2199-3-14**]**
Blood Culture, Routine (Final [**2199-3-14**]):
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN >= 4 MCG/ML.
VIRIDANS STREPTOCOCCI. SECOND MORPHOLOGY.
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
[**2199-3-9**] 3:30 pm BLOOD CULTURE 1 OF 2.
**FINAL REPORT [**2199-3-15**]**
Blood Culture, Routine (Final [**2199-3-15**]):
VIRIDANS STREPTOCOCCI.
SENSITIVITIES PERFORMED ON CULTURE # 340-0091M [**2199-3-8**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
Susceptibility testing requested by DR. [**Last Name (STitle) 4091**],[**First Name3 (LF) **]
PAGER [**Numeric Identifier **]
[**2199-3-13**]. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2199-3-13**] 7:50 pm BLOOD CULTURE
**FINAL REPORT [**2199-3-19**]**
Blood Culture, Routine (Final [**2199-3-19**]): NO GROWTH.
[**2199-3-19**] 10:59 am FLUID,OTHER
**FINAL REPORT [**2199-3-25**]**
GRAM STAIN (Final [**2199-3-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2199-3-22**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-3-25**]): NO GROWTH.
[**2199-3-8**] ABD CT:
IMPRESSION:
1. Stable peripancreatic fluid collections.
2. Possible splenic vein occlusion with mesenteric collaterals.
3. Fatty liver.
4. Splenomegaly.
[**2199-3-8**] CXR:
IMPRESSION: No acute cardiothoracic process
[**2199-3-14**] TTE/TEE:
Conclusions:
The left atrium is elongated. 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 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 aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
[**2199-3-19**] EKG:
Sinus bradycardia. Low limb lead voltage. Q-T interval
prolongation. Delayed precordial R wave transition. Compared to
the previous tracing of [**2199-3-14**] no diagnostic interim change.
[**2199-3-19**] Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 90962**],[**Known firstname **] [**2144-12-1**] 54 Male [**Numeric Identifier 90963**] [**Numeric Identifier 90964**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rate
SPECIMEN SUBMITTED: necrotic pancreatic tissues, pseudocyst
wall.
Procedure date Tissue received Report Date Diagnosed
by
[**2199-3-19**] [**2199-3-19**] [**2199-3-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/ttl
Previous biopsies: [**-1/4351**] GI BX'S (3 JARS)
DIAGNOSIS:
I. Necrotic pancreatic tissue, necrosectomy (A-B):
Diffusely necrotic tissue/debris; no viable pancreatic
parenchyma identified.
II. "Pseudocyst wall", gastrostomy (C-E):
Gastric corpus segment with no intrinsic mucosal abnormalities
and scant adherent cauterized fibrous tissue.
Brief Hospital Course:
Patient with history of necrotizing pancreatitis and pancreatic
pseudocyst was seen in clinic for follow up. During exam,
patient was found to have SBP in 80s and blood sugar 30. Patient
was admitted to General Surgery Service for further work up.
Blood cultures were sent on admission and was positive for Staph
COAG negative and Viridans strep. Patient's PICC line was
removed and he was started on IV Vancomycin, ID was consulted.
ID recommended 14 days course of IV Vancomycin. PICC line tip
and follow up blood cultures were negative, patient remained
afebrile with WBC within normal limits. On [**2199-3-19**], the patient
underwent pancreatic necrosectomy and pseudocyst-gastrostomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO, on IV fluids and
antibiotics, with a foley catheter, and Dilaudid PCA for pain
control. The patient was hemodynamically stable.
CV: Patient was found to have asymptomatic sinus bradycardia on
admission ECG. His Atenolol was held and he was placed on
telemetry for HR monitoring. He underwent echocardiography on
[**3-14**] which revealed normal LVEF and was grossly normal. Patient
had another episode of sinus bradycardia on [**3-14**] and repeat ECG
revealed prolonged d Q-T interval, patient's Quetiapine was
discontinued at this time. Pre-op ECG on [**3-19**] was stable and
post operatively patient remained stable from a cardiovascular
standpoint. Telemetry was discontinued on POD # 7, patient's HR
returned to sinus regular without any ectopy and home dose of
Atenolol was restarted. Quetiapine was not restarted on
discharge and patient was advised to discuss with his PCP
possible discontinue of this medication s/t causing Q-T
prolongation.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient's TPN was discontinued on admission ,and on
HD # 3 patient was started on full liquids diet with
supplements. Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient completed 14 days course of IV Vancomycin for
blood infection. TTE and TEE was nagative for any vegetations.
Follow up blood cultures were negative for any growth. Patient
underwent empirical treatment post operatively with Cipro and
Flagyl for infected pseudocyst. Final pseudocyst cultures were
negative and antibiotics were discontinued. The patient's white
blood count and fever curves were closely watched during
hospitalization and remained within normal limits prior
discharge.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. [**Last Name (un) **] Center
follow the patient daily and patient will continue to follow up
with endocrinology as outpatient.
Hematology/GI bleed: On POD # 4 patient was noticed hematemesis
x 2 and melena, his HCT had 10 points drop. The patient was
transferred in ICU for observation. Patient was transfused with
3 units of pRBC and 1 unit of FFP, his HCT improved after
transfusion (19.8->23.9). On POD # 5, patient continued to have
melena, no bloody emesis. He was transfused with 1 unit of pRBC
and transferred to the floor. Patient's HCT remains stable prior
discharge, no further transfusion were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diabetic diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
citalopram 20, lisinopril 10', omeprazole 20', quetiapine 100',
aspirin 81', atenolol 25', docusate sodium 100', senna 8.6'',
acetaminophen 325 q6h prn, oxycontin 20 mg Q8H.
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. quetiapine 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
10. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every eight (8) hours for 2
weeks: To refill this medication, please contact you PCP or [**Name9 (PRE) 1194**]
Specialist.
Disp:*42 Tablet Extended Release 12 hr(s)* Refills:*0*
11. Insulin Sliding Scale and Lantus
Insulin SC Fixed Dose Orders
Bedtime
Glargine 6 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL [**Name9 (PRE) **] with hypoglycemia protocol [**Name9 (PRE) **] with
hypoglycemia protocol [**Name9 (PRE) **] with hypoglycemia protocol [**Name9 (PRE) **]
with hypoglycemia protocol
71-200 mg/dL 0 Units 0 Units 0 Units 0 Units
201-250 mg/dL 3 Units 3 Units 3 Units 2 Units
251-300 mg/dL 4 Units 4 Units 4 Units 3 Units
301-350 mg/dL 6 Units 5 Units 6 Units 4 Units
351-400 mg/dL 7 Units 6 Units 7 Units 5 Units
Discharge Disposition:
Home
Discharge Diagnosis:
1. Necrotizing pancreatitis
2. Pancreatic psuedocyst
3. GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-13**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2199-4-19**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please follow up with [**Last Name (un) **] in [**3-8**] weeks after discharge.
Please call [**Telephone/Fax (1) 2378**] to make your appointment or if you have
any questions.
.
Please follow up with Dr. [**Last Name (STitle) 90965**] (PCP) in [**3-8**] weeks after
discharge.
Completed by:[**2199-3-28**]
|
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]
] |
15054, 15060
|
8673, 12859
|
328, 402
|
15169, 15169
|
3456, 8650
|
16427, 17062
|
2674, 2901
|
13084, 15031
|
15081, 15148
|
12885, 13061
|
15320, 15899
|
15914, 16404
|
2916, 2916
|
3206, 3437
|
263, 290
|
430, 1388
|
2930, 3192
|
15184, 15296
|
1410, 2271
|
2287, 2658
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,960
| 120,635
|
46572
|
Discharge summary
|
report
|
Admission Date: [**2184-4-3**] Discharge Date: [**2184-4-15**]
Date of Birth: [**2141-7-8**] Sex: M
Service: VASCULAR
Age: 42.
CHIEF COMPLAINT: Left foot cellulitis and dry gangrene of
toes 1, 2, and 3 on the left foot.
HISTORY OF THE PRESENT ILLNESS: The patient burned his left
foot one month ago on a space heater. He did not obtain
medical care initially. He was ultimately seen by Dr. [**Last Name (STitle) **].
He was placed on Augmentin without any effect. He was
admitted to our institution on [**2184-3-22**] for IV antibiotics
and operative planning. On [**2184-3-22**], the arterial
noninvasive showed bilateral tibial disease, significant. He
underwent MRA, which showed multiple proximal AT stenosis
with single-vessel runoff and a normal DP. Plan was to do an
AP popliteal to DP bypass graft. Given the patient's cardiac
history, a stress MIBI was done and on [**2184-3-24**] it showed
anterior and inferior wall reversible defects with an EF of
38%. Cardiac catheterization was done on [**2184-3-25**], which
showed an occluded LAD stent, RCA lesion, which was ablated
with radiation brachytherapy and angioplasty. The patient
agreed. The patient signed himself out against medical
advice on the last admission. The patient was given p.o.
Levofloxacin, Flagyl, and Aspirin in place of the IV
Imipenem.
He was seen in the clinic by Dr. [**Last Name (STitle) **] last week, who felt
that the patient's foot was more cellulitic than at the time
of discharge. The patient now was admitted for IV
antibiotics and anticipated left AK popliteal DP bypass
graft.
The patient denies any constitutional symptoms.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes type I with triopathy.
2. Coronary artery disease status post coronary artery
disease stent in [**2182-7-23**] with revision on [**3-23**].
3. Hypertension.
4. Hyperthyroidism.
5. Cervical degenerative disk disease.
PAST SURGICAL HISTORY: The patient had no previous surgical
interventions.
ALLERGIES: The patient is allergic to TETRACYCLINE.
Reaction was not documented.
MEDICATIONS
1. Lopressor 50 mg b.i.d.
2. Zestril 40 mg q.d.
3. Levoxyl 100 mg q.d.
4. Aspirin q.d.
5. NPH 28 units q.a.m. and 18 of regular q.a.m.
6. Levofloxacin 500 q.d.
7. Flagyl 500 t.i.d.
PHYSICAL EXAMINATION: Examination revealed the vital signs
of 98.1, 96, 126/86, 16. The patient is alert and in no
acute distress. HEENT: Intact. NECK: Supple. There is no
tracheal deviation. There were bilateral carotid bruits,
right greater than left. LUNGS: Lungs were clear to
auscultation bilaterally. HEART: Regular rate and rhythm
with no murmurs, rubs, or gallop. ABDOMEN: Soft, nontender,
nondistended. VASCULAR: Examination shows palpable
femorals, popliteals bilaterally with palpable DP and PT on
the right and Dopplerable signal DP and PT on the left. The
left foot is mildly erythematous, noninffected at the distal
dorsum and the mid-plantar aspect of the toes, 2, 1, and 3
are dry gangrene.
LABORATORY DATA: Labs revealed the following: CBC with
white count of 13.5, hematocrit 53.3, coagulations normal.
BUN 29, creatinine 2.0, potassium 5.6.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. He was placed on bed rest with the leg elevated.
He was allowed essential activities only. Routine labs were
obtained. [**Last Name (un) **] was consulted for diabetic management. He
had dry sterile dressings to his foot. Regarding
antibiotics, he was begun on Imipenem 500 mg q.8h. IV. He
was also given Kayexalate 30 grams times one for a potassium
of 5.6 There were no hyperkalemic changes in the EKG. He
was transfused one unit of packed cells for his admitting
hematocrit.
The patient underwent on [**2184-4-7**], a left AK popliteal to
dorsalis pedis bypass graft, nonreverse saphenous vein, and
angioscopy. The patient tolerated the procedure well. He
was transferred extubated to the PACU in stable condition
with a palpable DP pulse.
Immediately postoperatively, he remained hemodynamically
stable. The postoperative hematocrit was 26.1. Lopressor
dose was increased secondary to his tachycardia. He was
transferred to the VICU for continued monitoring and care.
On postoperative day #1, there were no overnight events.
Temperature maximum was 100. Lungs were clear to
auscultation. He continued to remain mildly tachycardiac
with a ventricular rate of 100. Incisions showed no
drainage, no hematoma, or palpable graft and DP pulse. The
Lopressor was converted to PO 50 mg b.i.d.
DIET: Diet was advanced as tolerated.
IV fluids were Hep Locked. Electrolytes were supplemented as
needed. Subcutaneous heparin was continued. The patient
remained in the VICU.
Orthopedic consultation was placed on [**2184-4-8**] because the
patient complained of bilateral upper extremity numbness and
muscle pain. The patient had known C spine disease and the
Department of Orthopedics recommended a cervical collar and
MRI of the cervical spine rule out acute process. MR
was done, which showed mild disk protrusion bilaterally at C5
and C6. The patient refused to wear a cervical collar. The
symptoms improved. He was placed on an insulin drip on
postoperative day #2 because of glucose of 451. The Podiatry
Department was consulted regarding the patient's toe lesions
and management. They felt that the best treatment would be a
TMA. On [**2184-4-9**], the patient underwent transmetatarsal
amputation without complication. The patient was continually
followed by the Orthopedic Department with recommendations.
The patient would eventually need an elective cervical spine
laminectomy and bone grafting. Infectious Disease was
consulted on [**2184-4-9**]. They recommended continuing current
antibiotic therapy. The patient required transfusion of one
unit of packed cells post TMA for blood loss anemia. The
Orthopedic Department recommended starting nonsteroidals to
help the inflammatory process and help control the pain.
Over the next 48 hours after re-application of the collar,
the patient noted improvement in his upper extremity
numbness. The patient was begun on Plavix secondary to his
coronary artery disease. The patient remained on strict bed
rest with his leg elevated. He was transferred to the
regular nursing floor. He did have a temperature spike on
postoperative day #3 and #1. He was pancultured. Chest
x-ray was obtained, which was negative. He was continued on
his Imipenem. The initial dressing on the foot was removed
on postoperative day #5. The wounds were clean, dry, and
intact. He was converted to his subacute insulin regimen
with stabilization of his glucose. Over the next twenty-four
hours, the temperature defervesced to 97.7. Foley catheter
was discontinued. Ambulation was begun on postoperative day
#4 and #6. The Department of Physical Therapy was to see the
patient and evaluate safety with crutch walking. The
antibiotics at the time of discharge were converted to
Levofloxacin and Flagyl, which he will continue for a total
of one week. He had arterial duplex done, which showed a
patent left popliteal DP graft. He continued to remain
afebrile. He was in stable condition and discharged to home.
The patient should followup with Dr. [**Last Name (STitle) **] in one week. He
will continue Levofloxacin and Flagyl until seen on followup.
He should followup with Dr. [**Last Name (STitle) 363**] of the Orthopedic
Department at his earliest convenience for further management
of his cervical disk radiculopathy.
DISCHARGE MEDICATIONS:
1. Flagyl 500 mg t.i.d.
2. Levaquin 500 mg q.d.
3. Ibuprofen 600 mg t.i.d. around the clock.
4. Plavix 75 mg q.a.m.
5. Lopressor 75 mg b.i.d.
6. Levothyroxine 100 mcg q.d.
7. Aspirin 325 mg daily.
8. Percocet 5/325 tablets one to two q.4h. to 6h.p.r.n.
pain.
9. Insulin 32 units NPH q.a.m. and 12 units NPH at bed time
with the Humalog sliding scale as follows:
BREAKFAST: Glucoses: 51 to 100 ten units; 101 to 150 twelve
units; 151 to 200 fourteen units; 201 to 250 fourteen units;
251 to 300 sixteen units; 301 to 350 eighteen units; 351 to
400 twenty units; greater than 400 twenty two units.
LUNCH: Sliding scale glucoses less than 200 no insulin: 201
to 250 four units; 251 to 300 six units; 301 to 350 eight
units; 351 to 400 ten units; greater than 400 ten units.
DINNER: Sliding scale Humalog as follows: Glucoses less
than 50 no insulin; 51 to 100 four units; 101 to 150 four
units; 151 to 200 six units; 201 to 250 eight units; 251 to
300 ten units; 301 to 350 twelve units; 351 to 400 fourteen
units; greater than 400 sixteen units.
BEDTIME: Humalog sliding scale glucoses less than 250 no
insulin; 251 to 300 four; 301 to 350 six; 351 to 400 eight;
greater than 400 eight.
DISCHARGE DIAGNOSES:
1. Dry gangrene cellulitis secondary to peripheral vascular
disease status post bypass graft on the left.
2. Status post TMA (transmetatarsal amputation).
3. Type I diabetic insulin dependent, control improved.
4. Blood loss anemia transfused and corrected.
5. Cervical radioculopathy, symptomatic, improved with
C- collar.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2184-4-14**] 11:08
T: [**2184-4-14**] 11:14
JOB#: [**Job Number 98877**]
|
[
"401.9",
"276.7",
"242.90",
"722.0",
"V45.82",
"285.1",
"440.24",
"682.7",
"250.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"99.20",
"84.12"
] |
icd9pcs
|
[
[
[]
]
] |
8814, 9414
|
7574, 8793
|
3193, 7551
|
1957, 2294
|
2317, 3175
|
168, 1659
|
1681, 1933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,543
| 125,083
|
51881
|
Discharge summary
|
report
|
Admission Date: [**2167-11-27**] Discharge Date: [**2167-12-4**]
Date of Birth: [**2095-1-29**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transferred from [**Hospital **] Hospital for mgmt of GI bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy with cauterization of a vessel.
History of Present Illness:
72-yo-woman w/ esoph CA metastatic to liver, CAD, and h/o
connective tissue dz transferred from OSH w/ GI bleed. She
presented to [**Hospital **] Hospital ED after having 2 melanic stools and
coffee ground emesis x 3. In the ED, BP 70/45, HR 79, O2 sat
100% 2L/m. She was observed to vomit coffee ground material by
hospital staff. She was treated w/ 1L NS IV, 1unit PRBCs, and
then admitted to Medicine service. Soon after admission, she
became dyspnic w/ O2 sat 81% on 100% NRB, ABG 7.35/27/81, and
was transferred to acute care unit.
.
The pt was treated w/ Unasyn IV for presumptive aspiration PNA,
though CXR demonstrated only mild LLL atelectasis. Subsequent
treatment of her hypoxia is unclear. EKG demonstrated afib w/
RVR (rate in 150s), which was treated w/ dilt gtt resulting in
conversion to NSR. She refused EGD for workup of GI bleed, as
she has an agreement to only have EGD by Dr. [**Last Name (STitle) 2305**], and thus
was transferred to [**Hospital1 18**] for further care.
.
Currently, she feels well except for minimal abd pain and cough
productive of scant yellow sputum. She denies any fever,
chills, chest pain, palps, dyspnea, nausea, dysuria.
.
Of note, the pt had EGD on [**2167-11-10**] demonstrating reflux
esophagitis, w/ bx of distal esophageal tumor.
Past Medical History:
1. Esophageal CA with liver mets s/p chemotx with Taxotere, 5-FU
and leucovorin with minimal residual disease
2. Irritable bowel syndrome
3. GERD
4. h/o diverticulitis
5. Colon polyps
6. Degenerative joint disease
7. Laryngeal polyps
8. Systemic lupus
9. Fibromyalgia
10. CAD s/p Anterior MI [**8-/2152**]
11. Osteoporosis
12. Macular Degeneration
13. Left patellar chondromalacia
Past Surgical Hx:
1. s/p cervical decompression [**1-/2153**]
2. h/o ruptured Gallbladder repair [**8-/2157**]
3. Right medial meniscus repair [**7-/2161**]
Social History:
No ETOH or smoking. Married.
Family History:
Positive for colon CA and Crohn's dz
Physical Exam:
1. Esophageal CA: s/p chemotx with Taxotere, 5-FU and
leucovorin with minimal residual disease, now w/ indwelling
esoph stent, metastatic to liver
2. Systemic lupus erythematosis
3. afib
4. CAD s/p anterior MI [**8-/2152**]
4. h/o diverticulitis
5. Colon polyps
6. Degenerative joint disease
7. Laryngeal polyps
8. GERD
9. Fibromyalgia
10. Osteoporosis
11. Macular Degeneration
12. Left patellar chondromalacia
13. Irritable bowel syndrome
Pertinent Results:
[**2167-12-3**] 04:23AM BLOOD WBC-20.5* RBC-3.57* Hgb-9.6* Hct-30.6*
MCV-86 MCH-26.8* MCHC-31.3 RDW-17.8* Plt Ct-208
[**2167-11-30**] 04:31AM BLOOD WBC-29.3* RBC-3.96* Hgb-10.8* Hct-32.3*
MCV-81* MCH-27.3 MCHC-33.5 RDW-17.9* Plt Ct-144*
[**2167-11-28**] 12:01PM BLOOD WBC-23.6* RBC-3.67* Hgb-10.2* Hct-30.7*
MCV-84 MCH-27.7 MCHC-33.1 RDW-17.5* Plt Ct-168
[**2167-11-28**] 08:10AM BLOOD Hct-27.0*
[**2167-11-29**] 03:30AM BLOOD Neuts-93.5* Bands-0 Lymphs-3.8* Monos-2.6
Eos-0 Baso-0
[**2167-11-28**] 12:01PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2167-12-3**] 04:23AM BLOOD Plt Ct-208
[**2167-12-3**] 04:23AM BLOOD Glucose-110* UreaN-33* Creat-0.4 Na-144
K-4.5 Cl-110* HCO3-26 AnGap-13
[**2167-11-30**] 04:31AM BLOOD Glucose-106* UreaN-27* Creat-0.4 Na-144
K-3.8 Cl-114* HCO3-20* AnGap-14
[**2167-11-28**] 12:40AM BLOOD Glucose-123* UreaN-41* Creat-0.4 Na-149*
K-3.0* Cl-121* HCO3-17* AnGap-14
[**2167-11-29**] 03:30AM BLOOD CK(CPK)-22*
[**2167-11-28**] 12:40AM BLOOD ALT-12 AST-14 LD(LDH)-183 AlkPhos-72
Amylase-43 TotBili-0.3
[**2167-11-28**] 12:40AM BLOOD Lipase-9
[**2167-11-29**] 03:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2167-12-3**] 04:23AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8
[**2167-11-29**] 03:30AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.3
[**2167-11-28**] 12:40AM BLOOD Albumin-2.4* Calcium-8.0* Phos-1.8*#
Mg-2.0
[**2167-11-29**] 11:49AM BLOOD Type-ART pO2-45* pCO2-30* pH-7.40
calHCO3-19* Base XS--4
[**2167-11-29**] 04:38AM BLOOD Type-ART pO2-59* pCO2-31* pH-7.38
calHCO3-19* Base XS--5
[**2167-11-29**] 04:38AM BLOOD Lactate-1.5
.
CXR [**11-28**]: Chest a single AP upright portable view at 12:50 a.m.
shows increased opacity in the left retrocardiac region with
obscuration of the left hemidiaphragm, indicating pneumonia.
There is blunting of the left costophrenic sulcus. The remainder
of the lungs are clear. The cardiomediastinal silhouette appears
normal. The right costophrenic sulcus is sharp. Note is made of
two rings related to esophageal stent at the region of the
gastroesophageal junction.
.
EKG [**11-28**]: Sinus rhythm. Diffuse non-diagnostic repolarization
abnormalities. Compared to
the previous tracing of [**2167-2-1**] multiple abnormalities as
previously noted
persist without major change.
.
Later EKGs not yet formally read alternated between afib with
rvr and NSR, not significantly changed otherwise.
.
EGD [**11-28**]:
Impression: 1. Severe esophagitis proximal to the esophageal
stent. In the mid esophagus was an ulcer with an adherent clot.
The clot was washed off, and a visible vessel was seen. The
vessel was treated with bicap electrocautery.
2. Diffuse gastritis. Coffee grounds in stomach.
3. Hyperplastic appearing granulation tissue at gastric cardia,
adjacent to distal end of esophageal stent. A nonbleeding ulcer
was seen within the granulation tissue.
4. Mild duodenitis at duodenal bulb.
Recommendations: Keep NPO for now.
Protonix 40 mg IV bid.
Carafate 1 gram slurry four times a day.
Keep head of bed elevated while supine, to minimize acid reflux
into esophagus.
Follow Hct.
Brief Hospital Course:
Mrs. [**Known lastname **] had an EGD for evaluation of GI bleed. An exposed
vessel was cauterized and the pt stable throughout the rest of
her hospital course with respect to her GI issues. She tolerated
a normal diet and had a stable hct.
The major issue during her hospitalization was her code status.
Her husband and health care proxy (HCP) on admission was her
husband, [**Name (NI) 565**]. During the hospitalization it became clear that
after multiple discussions with the house staff and attending,
that her wishes were to go home and have comfort measures only,
specifically DNR/DNI. There was no concern during her
hospitalization regarding her mental status as she was clear and
lucid throughout and articulated her feelings well. Her husband
adamantly disagreed and "wanted everything done." He treated the
staff poorly, including intimidating nurses and attempting to
intimidate house staff by threatening legal action if his wishes
were not followed. Through family meetings without his presence,
the patient elected to change her HCP to her sister, [**Name (NI) **]. The
appropriate DNR/DNI form was filled out, including a bracelet to
attempt to prevent anyone from circumventing her wishes were she
to become unresponsive. Her sister and health care providers
(Dr. [**First Name (STitle) **], oncology, and Dr. [**Last Name (STitle) 1940**], GI) were made aware of
this development.
Her medical issues following the EGD of note revolved around her
afib. She was well maintained on low dose oral beta blocker and
an amiodarone ggt. Multiple times she had the amio ggt
discontinued and had subsequent episodes of return to afib w/
rvr w/ chest pain resolved by nitro and iv metoprolol. Her dose
of metoprolol was escalated to 75mg po tid and the amio was
ultimately successfully converted to PO 400mg [**Hospital1 **] after
discussion with the cardiology/EP fellow. She was then
discharged stable on this regimen with instructions to f/u if
her symptoms bother her. She was also given nitroglycerine SL
PRN for chest pain.
She was discharged in stable condition on HOD 7.
Medications on Admission:
1. atenolol 25mg daily
2. nifedipine 10mg TID prn [**Name (NI) 25670**] (pt not taking this at
home)
3. amiloride/HCTZ 5/50mg QOD
4. imdur 30mg daily
5. norvasc 5mg daily
6. nitroglycerin SL prn chest pain
7. lipitor 40mg daily
8. zantac 150mg [**Hospital1 **]
9. reglan 10mg QACHS
10. zofran 8mg PO BID prn nausea
11. ativan 0.5-1mg qhs prn
12. demerol prn pain
13. morphine 15-30mg PO q 4 hours prn pain
14. tobradex eye gtt in right eye for 5 days
Discharge Medications:
1. Oxygen-Air Delivery Systems Device Sig: One (1) Miscell.
once a day: Please dispense one non-rebreather and one nasal
cannula for oxygen administration and the associated supplies so
the patient can receive 15LPM by NRB and 6 L by NC.
Disp:*1 package* Refills:*2*
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take tablet every 5 minutes with a maximum of 3 total. Call your
primary doctor or 911 if the chest pain does not resolve after
the 3rd dose.
Disp:*20 Tablet, Sublingual(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for sleep induction.
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Do not take more than 10 tablets in 24
hours.
Disp:*30 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: Take until all the tablets are gone.
Disp:*3 Tablet(s)* Refills:*0*
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
8. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: 2-4 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Ipratropium Bromide 0.02 % Solution Sig: [**1-11**] nebulized
solution Inhalation Q6H (every 6 hours) as needed.
Disp:*qs nebulized solution* Refills:*0*
14. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed) as needed for eye dryness.
Disp:*qs bottle* Refills:*0*
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
16. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain: Withold the medicine if
your breathing is slowed or if you feel sedated. Do not drive a
car while on this medicine.
Disp:*30 Tablet(s)* Refills:*0*
17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1121**] VNA and hospice
Discharge Diagnosis:
Gastrointestinal bleed, now resolved.
Hypoxia, persistent.
Atrial fibrillation.
Coronary artery disease.
Esophageal cancer with metastases to the liver, quiescent
currently.
Hypertension.
Gastroparesis.
Discharge Condition:
Stable.
Discharge Instructions:
Continue to use your oxygen as you have in the hospital for
comfort. Also, continue to take the Metoprolol and Amiodarone to
control your "afib" (atrial fibrillation). You should take the
nitroglycerine as needed for chest discomfort. You should call
your primary care doctor for any (Dr. [**Last Name (STitle) 7474**] [**Telephone/Fax (1) 37466**] or Dr.
[**Last Name (STitle) 50640**] [**Telephone/Fax (1) 14771**]) if you have any issues that make you
uncomfortable or any other concerns.
Followup Instructions:
Call your primary doctor for follow up within one to two weeks
or sooner if you are having discomfort or pain. Also, there are
three appointments that you already have scheduled below in the
future.
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-12-16**] 2:00
Provider: [**Name10 (NameIs) 11383**],[**Name11 (NameIs) 11384**] OB/GYN PPS CC8 (SB) Date/Time:[**2167-12-22**]
1:15
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] HEM ONC Date/Time:[**2167-12-24**] 12:30
|
[
"285.9",
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"710.0",
"414.01",
"427.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
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] |
icd9pcs
|
[
[
[]
]
] |
11305, 11376
|
5963, 8051
|
332, 393
|
11623, 11633
|
2856, 5940
|
12173, 12722
|
2342, 2380
|
8552, 11282
|
11397, 11602
|
8077, 8529
|
11657, 12150
|
2395, 2837
|
230, 294
|
421, 1715
|
1737, 2278
|
2294, 2326
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,765
| 192,465
|
45532+58824+58825+58833
|
Discharge summary
|
report+addendum+addendum+addendum
|
Admission Date: [**2177-3-15**] Discharge Date: [**2177-3-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Hypernatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo wheelchair-bound F w/ h/o dementia, CVA , mult asp PNA,
recurrent UTIs presents from Na 168, decreased MS. [**First Name (Titles) **] [**Name (NI) **], pt
was treated since [**2177-3-7**] for UTI (cx data not available) w/
levo and vancomycin. NH noted progressive lethargy for the last
3 days; the patient has not been eating/taking medications for
the last 3 days. Labs were obtained today, and pt transported to
the ED for Na 168. In ED, HR 86, bpc 138/76, resp 18, 87% 5L ->
99% NRB. She received ceftriaxone and levofloxacin for presumed
pneumonia and was started on 1L NS. CXR and CT head negative. 02
rapidly weaned to 2L NC and patient sent to ICU for sodium
correction and neurologic monitoring.
.
[**Hospital Unit Name 153**] course c/b decreased MS, somewhat improved with IVF
repletion. Had episodes of sinus bradycardia thought [**1-22**]
metabolic derangements. Was started on meropenem for ESBL
resistant organisms for UTI and transferred to the floor once
MS/hypernatremia improved.
Past Medical History:
1) Left hemorrhagic CA [**2169**] w/ residual left-sided paralysis
2) Multiple prior aspiration pneumonias on pureeed solids at
nursing home
3) UGI bleed [**2174**], managed conservatively
4) h/o rectal bleeding
5) h/o C. diff colitis
6) h/o diverticulitis
7) dementia
8) severe constipation requiring multiple admissions for
LBO/disimpaction
9) CHF: [**2163-11-2**] TTE: hyperdynamic LV, mild-mod MR
10) GERD
11) Atrial Fibrillation ??
12) Eye implant
Social History:
Lives at [**Hospital1 8218**] Health and Rehab Center; wheelchair bound. No
EtOH, tobacco, or other drug use. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 97129**] [**Telephone/Fax (1) 60586**].
Family History:
NC
Physical Exam:
Tc 99.8, pc 74, bpc 134/80, resp 16 97% 100% NRB
Gen: elderly, cachectic female, lethargic, does not follow
commands
HEENT: PERRL, thick discharge from eyes bilaterally, mild
conjunctival injection, OMM very dry, poor dentition, neck
supple, no LAD, no JVD, normocephalic, atraumatic
Cardiac: RRR, II/VI SM at apex
Pulm: Coarse breath sounds w/ occasional ronchi
Abd: NABS, soft, NT/ND, no masses
Ext: No C/C/E, warm with 2+ DP bilaterally
Neuro: face symmetrical, PERRL, resists eyes opening, weak gag,
moves RUE and RLE >LLE in response to painful stimulus; does not
move LUE in response to pain. 1+ DTR throughout, does downgoing
right, withdrawal on left.
Pertinent Results:
EKG: ED Sinus? @ 75 bpm, downsloping [**Street Address(2) 4793**] depressions V4-V6
(new from prior. Old PRWP.
In [**Hospital Unit Name 153**]: Afib at approx. 70 BPM
*
CXR: ? Minimal, patchy RLL infiltrate
.
[**2177-3-14**] PT-13.7* PTT-27.2 INR(PT)-1.2
[**2177-3-14**] PLT COUNT-135*
[**2177-3-14**] NEUTS-62.6 LYMPHS-31.4 MONOS-2.8 EOS-0.7 BASOS-2.4*
[**2177-3-14**] WBC-4.9 RBC-5.57*# HGB-17.1*# HCT-53.4*# MCV-96#
MCH-30.7 MCHC-32.0 RDW-15.3
[**2177-3-14**] TSH-2.0
[**2177-3-14**] ALBUMIN-4.1 CALCIUM-10.2 PHOSPHATE-3.0 MAGNESIUM-3.2*
[**2177-3-14**] ALT(SGPT)-59* AST(SGOT)-73* CK(CPK)-33 ALK PHOS-241*
AMYLASE-40 TOT BILI-1.8*
[**2177-3-14**] GLUCOSE-109* UREA N-50* CREAT-1.0 SODIUM-169*
POTASSIUM-3.9 CHLORIDE-126* TOTAL CO2-31* ANION GAP-16
[**2177-3-14**] URINE RBC-0-2 WBC-[**11-9**]* BACTERIA-MOD YEAST-NONE
EPI-[**2-22**]
[**2177-3-14**] URINE BLOOD-SM NITRITE-POS PROTEIN-TR GLUCOSE-NEG
KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM
[**2177-3-14**] URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
Brief Hospital Course:
[**Age over 90 **] yoF w/ h/o mult asp PNA, recently dx UTI, dementia, prior CVA
admit with decreased MS [**1-22**] hypernatremia.
.
1) Hypernatremia: Initial Na 168. Presentation consistent with
loss of hypotonic fluid with decreased free H20 intake/access
due to being non-ambulatory (wheelchair bound). Patient was
aggressively hydrated with slow correction of sodium to within
normal limits, with improvement in mental status. At time of
her discharge, her sodium was back to baseline 140.
.
2) Decreased MS: Thought to be multifactorial including
hypernatremia and urinary infection. Had Head CT on admission,
negative for acute bleed. Pt also with underlying dementia,
which is unchanged. Her medications for dementia were
discontinued during her hospitalization. At this time, we did
not feel we should restart these meds; this can be discussed
with her outpatient physician.
.
3) UTI: Pt w/ h/o recurrent UTIs, with U/A on admission
consistent with UTI; however, urine culture taken the same day
was contaminated. Given patient's past h/o infections with ESBL
resistant organisms was placed on meropenem x 5 days. F/u U/A,
urine cultures showed clearance of infection, so antibiotics
were d/c after 5 days. (There was concern that meropenem was
contributing to her LFT abnormalities/thrombocytopenia, so a
prolonged course was not favored. Given a nl U/A/urine culture,
we felt comfortable d/c her antibiotics).
***PLEASE NOTE, pt had a U/A, urine culture sent on the day of
discharge given her h/o recurrent UTIs. Dr. [**Last Name (STitle) **], the attending
on the case, will follow up on the results and report if
treatment is required.
.
4) EKG changes/Afib: Patient had EKG changes, new from baseline.
Was r/o for MI in the [**Hospital Unit Name 153**]; had mild TPN leak thought [**1-22**]
demand ischemia from dehydration/infection.
Aspirin was held in setting of low platelets. No further
work-up was pursued.
.
5) Thrombocytopenia:
Pt with low nl platelets in the past, with decreased platelets
during her hospitalization. Meropenem was implicated, and d/c
as soon as f/u U/A, urine cultures were negative. HIT Ab was
negative. On day of discharge, platelets were back to her
baseline, low 100s.
.
6) Abnl LFTs: Had transaminitis w/elevated LDH/Alk Phos and nl
bilirubin. RUQ u/s showed sludge but no stones/cholecystitis.
Abnormalities were thought ? [**1-22**] meds (meropenem), but not
entirely clear. Still following with slow resolution of
abnormalities; patient asymptomatic.
.
7) F/E/N: Pt w/ recurrent aspirations on pureed solids at
nursing home. Had bedside speech/swallow evaluation which
confirmed this propensity. Recommended nectar thickened
liquids/aspiration precautions. Please, please make sure
patient eats/drinks to avoid hypernatremia. Given her
wheel-chair bound status, she cannot get her own fluids. If she
is not eating, she will need D5 1/2NS maintenance IVF to avoid
dehydration/hypernatremia.
***If patient is not eating for several days, may need to
re-discuss the issue of a feeding tube with patient's health
care proxy/son, [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 97130**].
.
8) Proph: Pneumoboots; No heparin/H2 blockers/PPI in setting of
low platelets.
***Aggressive bowel regimen (daily colace/senna unless patient
has diarrhea; add bisacodyl/lactulose if patient not having BM x
2 days) as has needed disimpaction in past.
.
9) DNR/DNI: HCP [**Name (NI) **] [**Name (NI) **] (son) [**Telephone/Fax (1) 97131**]
.
10) Access-Patient was not eating well during her
hospitalization and required IVF. She had a PICC line placed on
day of discharge [**2177-3-21**] for IVF as needed
Medications on Admission:
1) Duoneb q6h prn
2) Trazodone 25 mg PO qhs prn
3) Tylenol prn
4) Colace 100 mg PO BID
5) senna 1 tab PO BID prn
6) Glycolax 17g PO prn
7) Protonix 40 mg PO daily
8) MOM prn
9) Aricept 10 mg PO daily
10) Namendal 10 mg PO BID
11) Mucinex 600 mg PO BID
12) levoquin 250 mg PO daily
13) ?vancomycin
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) dose PO BID
(2 times a day): Hold for diarrhea.
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): Hold for diarrhea.
3. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed for agitation.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: Patient has history of impaction; if no BM x 2
days, please be aggressive with bowel regimen.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] HOUSE, INC.
Discharge Diagnosis:
Hypernatremia
Urinary Tract Infection
Discharge Condition:
Patient is urinating, having bowel movements and tolerating POs
(aspiration precautions). She is wheel-chair bound at baseline
but is working with physical therapy to assist in transfers.
Discharge Instructions:
Patient should take her medications as prescribed. It is
imperative that she eats/drinks to avoid getting dehydrated. If
she is not eating, PLEASE give her maintenance IVF D5 1/2NS at
75cc/hr. This can be stopped if she is eating.
Followup Instructions:
Patient should call her primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 60585**]
([**Telephone/Fax (1) 97132**] and make an appointment to see him next week.
Completed by:[**0-0-0**] Name: [**Known lastname **],[**Known firstname 6691**] Unit No: [**Numeric Identifier 15459**]
Admission Date: [**2177-3-15**] Discharge Date: [**2177-3-21**]
Date of Birth: [**2082-6-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 923**]
Addendum:
This is the replacement D/C summary
Chief Complaint:
Hypernatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo wheelchair-bound female nursing home resident with a
history of a large right hemispheric stroke,dementia, multiple
aspiration pneumonias, recurrent UTIs presents with decreaseing
oral intake, lethargy and hypernatremia (Na 168. Per [**Name (NI) 2090**], pt was
treated since [**2177-3-7**] for UTI (cx data not available) w/
levofloxacin and vancomycin. NH noted progressive lethargy for
the last 3 days; the patient has not been eating/taking
medications for the last 3 days. Labs were obtained today, and
pt transported to the ED for Na 168. In ED, HR 86, bpc 138/76,
resp 18, 87% 5L -> 99% NRB. She received ceftriaxone and
levofloxacin for presumed pneumonia and was started on 1L NS.
CXR and CT head negative. 02
rapidly weaned to 2L NC and patient sent to ICU for sodium
correction and neurologic monitoring.
[**Hospital Unit Name 1863**] course c/b decreased MS, somewhat improved with IVF
depletion. Had episodes of sinus bradycardia thought [**1-22**]
metabolic derangements. Was empirically started on meropenem
for history of ESBL resistant organisms for UTI and transferred
to the floor once MS/hypernatremia improved.
Past Medical History:
1) Right hemorrhagic CA [**2169**] w/ residual left-sided paralysis
2) Multiple prior aspiration pneumonias on pureeed solids at
nursing home
3) UGI bleed [**2174**], managed conservatively
4) h/o rectal bleeding
5) h/o C. diff colitis
6) h/o diverticulitis
7) dementia
8) severe constipation requiring multiple admissions for
LBO/disimpaction
9) CHF: [**2163-11-2**] TTE: hyperdynamic LV, mild-mod MR
10) GERD
11) Atrial Fibrillation ??
12) Eye implant
Social History:
Lives at [**Hospital1 **] Health and Rehab Center; wheelchair bound. No
EtOH, tobacco, or other drug use. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15460**] [**Telephone/Fax (1) 15461**].
Family History:
NC
Physical Exam:
Tc 99.8, pc 74, bpc 134/80, resp 16 97% 100% NRB
Gen: elderly, cachectic female, lethargic, does not follow
commands
HEENT: PERRL, thick discharge from eyes bilaterally, mild
conjunctival injection, OMM very dry, poor dentition, neck
supple, no LAD, no JVD, normocephalic, atraumatic
Cardiac: RRR, II/VI SM at apex
Pulm: Coarse breath sounds w/ occasional ronchi
Abd: NABS, soft, NT/ND, no masses
Ext: No C/C/E, warm with 2+ DP bilaterally
Neuro: face symmetrical, PERRL, resists eyes opening, weak gag,
moves RUE and RLE >LLE in response to painful stimulus; does not
move LUE in response to pain. Increased tone left side. 1+ DTR
throughout, does downgoing
right, withdrawal on left.
Pertinent Results:
EKG: ED Sinus? @ 75 bpm, downsloping [**Street Address(2) **] depressions V4-V6
(new from prior. Old PRWP.
In [**Hospital Unit Name 1863**]: Afib at approx. 70 BPM
*
CXR: ? Minimal, patchy RLL infiltrate
.
[**2177-3-14**] PT-13.7* PTT-27.2 INR(PT)-1.2
[**2177-3-14**] PLT COUNT-135*
[**2177-3-14**] NEUTS-62.6 LYMPHS-31.4 MONOS-2.8 EOS-0.7 BASOS-2.4*
[**2177-3-14**] WBC-4.9 RBC-5.57*# HGB-17.1*# HCT-53.4*# MCV-96#
MCH-30.7 MCHC-32.0 RDW-15.3
[**2177-3-14**] TSH-2.0
[**2177-3-14**] ALBUMIN-4.1 CALCIUM-10.2 PHOSPHATE-3.0 MAGNESIUM-3.2*
[**2177-3-14**] ALT(SGPT)-59* AST(SGOT)-73* CK(CPK)-33 ALK PHOS-241*
AMYLASE-40 TOT BILI-1.8*
[**2177-3-14**] GLUCOSE-109* UREA N-50* CREAT-1.0 SODIUM-169*
POTASSIUM-3.9 CHLORIDE-126* TOTAL CO2-31* ANION GAP-16
[**2177-3-14**] URINE RBC-0-2 WBC-[**11-9**]* BACTERIA-MOD YEAST-NONE
EPI-[**2-22**]
[**2177-3-14**] URINE BLOOD-SM NITRITE-POS PROTEIN-TR GLUCOSE-NEG
KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM
[**2177-3-14**] URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 418**]-1.022
Brief Hospital Course:
[**Age over 90 **] yoF w/ h/o mult aspiration pneumonias, recently dx UTI,
dementia, prior stroke
admit with decreasing oral intake, lethargy and hypernatremia.
.
1) Hypernatremia: Initial Na 168. Presentation consistent with
loss of hypotonic fluid with decreased free H20 intake/access
due to being non-ambulatory (wheelchair bound, and an overall
decreased interest in food and fluids. Patient was aggressively
hydrated with slow correction of sodium to within normal limits,
with improvement in mental status. At time of her discharge,
her sodium was back to baseline 140.
.
2) Decreased MS: Thought to be multifactorial including
hypernatremia and urinary infection. Had Head CT on admission,
negative for acute bleed. Pt also with underlying dementia,
which is unchanged. Her medications for dementia (donepizil and
memantine) were discontinued during her hospitalization. At
this time, we did
not feel we should restart these meds; this can be discussed
with her nursing home physician.
.
3) UTI: Pt w/ h/o recurrent UTIs, with U/A on admission
consistent with UTI; however, urine culture taken the same day
was contaminated. Given patient's past h/o infections with ESBL
resistant organisms was placed on meropenem x 5 days. F/u U/A,
urine cultures showed clearance of infection, so antibiotics
were d/c after 5 days. (There was concern that meropenem was
contributing to her LFT abnormalities/thrombocytopenia, so a
prolonged course was not favored. Given a nl U/A/urine culture,
we felt comfortable d/c her antibiotics).
.
4) EKG changes/Afib: Patient had EKG changes, new from baseline.
Was r/o for MI in the [**Hospital Unit Name 1863**]; had mild troponin "leak" thought to
be due to demand ischemia from dehydration/infection. Aspirin
was held in setting of low platelets. No further work-up was
pursued.
.
5) Thrombocytopenia:
Pt with low nl platelets in the past, with decreased platelets
during her hospitalization. Meropenem was implicated, and d/c
as soon as f/u U/A, urine cultures were negative. HIT Ab was
negative. On day of discharge, platelets were back to her
baseline, low 100s.
.
6) Abnl LFTs: Had transaminitis w/elevated LDH/Alk Phos and nl
bilirubin. RUQ u/s showed sludge but no stones/cholecystitis.
Abnormalities were thought to be secondary to meds (meropenem),
but not entirely clear. Still following with slow resolution of
abnormalities; patient asymptomatic.
.
7) F/E/N: Pt w/ recurrent aspirations on pureed solids at
nursing home. Had bedside speech/swallow evaluation which
confirmed this propensity. Recommended nectar thickened
liquids/aspiration precautions. It is anticipated that
recurrent dehydration and hypernatremia will be a problem if
Mrs. [**Known lastname 690**] refused to eat. If she
is not eating, she will need D5 1/2NS maintenance IVF to avoid
dehydration and hypernatremia. A PICC line was inserted prior
to transfer to facilitate this approach in the coming week. If
patient is not eating for several days, may need to
re-discuss the issue of a feeding tube with patient's health
care proxy/son, [**Name (NI) **] [**Name (NI) 690**] ([**Telephone/Fax (1) 15462**].
.
8) Proph: Pneumoboots; No heparin/H2 blockers/PPI in setting of
low platelets.
***Aggressive bowel regimen (daily colace/senna unless patient
has diarrhea; add bisacodyl/lactulose if patient not having BM x
2 days) as has needed disimpaction in past.
.
9) DNR/DNI: HCP [**Name (NI) **] [**Name (NI) 690**] (son) [**Telephone/Fax (1) 15463**]
.
10) Access-Patient was not eating well during her
hospitalization and required IVF. She had a PICC line placed on
day of discharge [**2177-3-21**] for IVF as needed
Medications on Admission:
1) Duoneb q6h prn
2) Trazodone 25 mg PO qhs prn
3) Tylenol prn
4) Colace 100 mg PO BID
5) senna 1 tab PO BID prn
6) Glycolax 17g PO prn
7) Protonix 40 mg PO daily
8) MOM prn
9) Aricept 10 mg PO daily
10) Namendal 10 mg PO BID
11) Mucinex 600 mg PO BID
12) levoquin 250 mg PO daily
13) ?vancomycin
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) dose PO BID
(2 times a day): Hold for diarrhea.
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): Hold for diarrhea.
3. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) as needed for agitation.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: Patient has history of impaction; if no BM x 2
days, please be aggressive with bowel regimen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 163**] - [**Location (un) 164**]
Discharge Diagnosis:
Hypernatremia
Urinary Tract Infection
Discharge Condition:
Patient is urinating, having bowel movements and tolerating POs
(aspiration precautions). She is wheel-chair bound at baseline
but is working with physical therapy to assist in transfers.
Discharge Instructions:
Patient should take her medications as prescribed. It is
imperative that she eats/drinks to avoid getting dehydrated. If
she is not eating, PLEASE give her maintenance IVF D5 1/2NS at
75cc/hr. This can be stopped if she is eating.
Followup Instructions:
Patient should call her primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15460**]
([**Telephone/Fax (1) 15464**] and make an appointment to see him next week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 927**] MD [**MD Number(1) 928**]
Completed by:[**2177-3-21**] Name: [**Known lastname **],[**Known firstname 6691**] Unit No: [**Numeric Identifier 15459**]
Admission Date: [**2177-3-15**] Discharge Date: [**2177-3-21**]
Date of Birth: [**2082-6-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 923**]
Addendum:
Patient's future PCP will be Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of the Gerontology
Department at the [**Hospital1 8**].
This discharge to [**First Name4 (NamePattern1) 14703**] [**Last Name (NamePattern1) **] IS A BRIDGE TO HOME HOSPICE.
PLEASE HELP WITH THE TRANSITION TO HOME HOSPICE.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 163**] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 927**] MD [**MD Number(1) 928**]
Completed by:[**0-0-0**] Name: [**Known lastname **],[**Known firstname 6691**] Unit No: [**Numeric Identifier 15459**]
Admission Date: [**2177-3-15**] Discharge Date: [**2177-3-21**]
Date of Birth: [**2082-6-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 923**]
Addendum:
Patient's future PCP will be Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of the Gerontology
Department at the [**Hospital1 8**].
This discharge to [**First Name4 (NamePattern1) 14703**] [**Last Name (NamePattern1) **] IS A BRIDGE TO HOME HOSPICE.
PLEASE HELP WITH THE TRANSITION TO HOME HOSPICE.
Brief Hospital Course:
Patient's future PCP will be Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of the Gerontology
Department at the [**Hospital1 8**].
This discharge to [**First Name4 (NamePattern1) 14703**] [**Last Name (NamePattern1) **] IS A BRIDGE TO HOME HOSPICE.
PLEASE HELP WITH THE TRANSITION TO HOME HOSPICE.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 163**] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 927**] MD [**MD Number(1) 928**]
Completed by:[**0-0-0**]
|
[
"791.5",
"799.4",
"790.4",
"496",
"294.8",
"427.89",
"287.5",
"427.31",
"438.20",
"599.0",
"276.0",
"293.0",
"E947.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20926, 21149
|
20590, 20903
|
9694, 9701
|
18100, 18290
|
12337, 13372
|
18572, 19620
|
11609, 11613
|
17409, 17923
|
18039, 18079
|
17088, 17386
|
18314, 18549
|
11628, 12318
|
9640, 9656
|
9729, 10889
|
10911, 11368
|
11384, 11593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,371
| 143,042
|
24031
|
Discharge summary
|
report
|
Admission Date: [**2156-2-13**] Discharge Date: [**2156-2-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac cath
History of Present Illness:
This is a 80yo gentleman with history of colorectal cancer, s/p
colostomy chemo/XRT with porta cath and on coumadin who
presented to the OSH with progressive chest pain since 8PM last
night. EKG at OSH had inferior ST elevtions with suggestion of
posterior changes. He was made pain free with nitro gtt and
lopressor and ASA and was transferred for cardiac
catheterization. At OSH, his INR was 2.2. He underwent cardiac
cath with stent(DES) to the LCX and TO of RCA. He had oozing
from the sheath requiring sheath change complicated by hematoma
requiring admission to CCU. Post cath, EKG showed unresolved ST
elevation, He was given nipride IC/NTG IC without changes. He
received 4u FFP in the cath lab.Currently, he denies chest
pain/shortness of breath.
Past Medical History:
1. colon CA s/p abdominoperineal resection with
colostomy/XRT/chemo
2. portacath on coumadin
3, hypercholesterolemia
4. hypertension
5. gout
Social History:
smoke, quit ETOH in [**2140**]
Physical Exam:
GEN-NAD, A+O x3
HEENT-anicteric, MMM, neck supple
CV-RRR, no r/m/g, noS3/S4
resp-CTAB(anterior exam)
[**Last Name (un) 103**]-soft, NT/ND
extremities- right groin in pressure dressing, no pitting edema,
DP 1+b/l
Pertinent Results:
perverbal report
TO RCA s/p DES
90% pLCx s/p DES
PCWP14
ECG post cath NSR at 50bpm, normal axis, 1st degree AVB, ST
elevation, Q and TWI in II, III, aVF
1. Two vessel coronary artery disease.
2. Acute inferoposterior MI, terminated by primary PCI.
3. Stenting of the RCA and LCX.
4. Normal filling pressures.
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
an angiographically normal LMCA. The LAD had a 70% lesion after
D1. THe
LCX had a 90% proximal stenosis. The RCA had a mid subtotal
occlusion
followed by a long segment of moderate disease with TIMI 2 flow;
there
was a 30% lesion before the PDA.
2. Hemodynamics after PCI showed a severely depressed CI at 1.5.
3. Successful stenting of the RCA was performed with overlapping
3.5 x
33 mm, 3.0 x 8 mm and 3.0 x 8 mm Cypher DES.
4. Stenting of the LCX was performed with a 3.0 x 13 mm Cypher
DES.
Brief Hospital Course:
80yo M with h/o HTN, hypercholesterolemia, colon cancer now with
IMI post RCA and LCx stent c/b groin hematoma. He was admitted
to the CCU for monitoring of the groin hematoma. Overnight, the
hematoma is stable. His hematocrit remained stable and he has
good pulses in his lower extremities. He will continue on
aspirin, plavix x 9 months, beta blocker and lipitor.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 300 days.
Disp:*300 Tablet(s)* Refills:*0*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
MI s/p stenting
Discharge Condition:
good
Discharge Instructions:
Please take all of your medications as directed. IT IS VERY
IMPORTANT THAT YOU TAKE YOUR PLAVIX (CLOPIDOGREL). If you do not
take this medication, you may have a second heart attack. Call
your doctor or return to the emergency department if you
experience chest pain, shortness of breath or other symptoms
that are concerning to you.
Followup Instructions:
Please follow up with your primary doctor within one week. You
will also need to follow up with a cardiologist in 2 to 4 weeks.
Call ([**Telephone/Fax (1) 2037**] in order to make an appointment with a
cardiologist here at [**Hospital3 **], or you may make an appointment
with a cardiologist nearer to your home. Please bring this
imformation with you when you go to your appointment.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2156-2-27**]
|
[
"410.71",
"414.01",
"998.12",
"401.9",
"274.9",
"285.9",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.20",
"36.07",
"36.05",
"37.21",
"88.56",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
3409, 3415
|
2449, 2817
|
273, 287
|
3475, 3481
|
1536, 2426
|
3863, 4405
|
2840, 3386
|
3436, 3454
|
3505, 3840
|
1303, 1517
|
223, 235
|
315, 1074
|
1096, 1239
|
1255, 1288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,744
| 133,863
|
42905
|
Discharge summary
|
report
|
Admission Date: [**2200-11-21**] Discharge Date: [**2200-11-24**]
Date of Birth: [**2175-8-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11399**]
Chief Complaint:
shortness of breath, wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 25 year old female with a past medical history of
asthma who presents with dyspnea.
.
Patient reports that over the last several months, she has been
waking up almost daily in the middle of the night to use her
albuterol inhaler. Over the last several days, her breathing
has also worsened due to the development of subjective fever,
chills, and a nonproductive cough. While she has used her
albuterol inhaler very sparingly during the day, she has
increased its use to up to 3 times every night for the last
several evenings. Earlier today, she began to develop dyspnea,
wheezing. Patient denies chest pain, palpitations, orthopnea,
PND, or lower extremity swelling. Of note, patient reports that
her last asthma exacerbation was 7 years prior, when she
required ICU admission for observation without intubation.
.
In the ED inital vitals were, 98.6 120 154/105 30 87%RA. Her
initial exam was significant for use of accessory muscles, RR
40s-50s, ronchi throughout w/exp wheezing, decreased air
movement bilaterally. Her inital peak flow was 162. She was
given 1L NS, 2 sets of albuterol and ipratropium nebs,
methylprednisone 125mg IV X 1, and 2g magnesium sulfate IV X 1.
A chest xray demonstrated no acute cardiopulmonary findings.
Labs were significant for a venous lactate of 1.4 and CBC with
diff significant for eos of 5.5.
.
Prior to transfer, vital signs were: P: 96, BP: 123/63, RR: 16,
93% on 5L NC. Patient was admitted to ICU due to difficulty
with spacing nebulizer treatments beyond 1/2 hour intervals.
.
On arrival to the ICU, patient is sleepy, reports that she feels
much better, her breathing is now at baseline. She reports that
her cough has also improved. She would like to go home as soon
as possible. History obtained is limited.
Past Medical History:
1. Asthma
2. Anxiety
3. Hepatitis C, on no current medications
Social History:
- Tobacco: Smokes [**12-23**] cigarettes daily for at least 6 years.
- Alcohol: Social, denies heavy usage.
- Illicits: Denies.
Family History:
Asthma in her Mother.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.1, BP: 112/56, P: 88, R: 15, O2: 92%RA.
General: Alert, oriented, no acute distress, talking in full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Scattered wheezes, chest with adequate air movement. No
accessory muscle use. No rales or crackles.
CVS: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+OX3. No focal deficits.
Discharge Physical Exam:
Vitals: T: 98.2, BP: 118/58, P: 76, R: 18, O2: 97%RA.
General: Alert, oriented, no acute distress, talking in full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no w/r/r
CVS: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+OX3. No focal deficits.
Pertinent Results:
Admission labs:
WBC-8.1 RBC-4.09* HGB-11.9* HCT-38.0 MCV-93 MCH-29.1 MCHC-31.3
RDW-12.8
NEUTS-66.0 LYMPHS-25.3 MONOS-2.8 EOS-5.5* BASOS-0.3
GLUCOSE-112* LACTATE-1.4 NA+-143 K+-3.3 CL--98 TCO2-31* UREA N-8
CREAT-0.7
HCG-<5
Microbiology:
Blood cultures [**2200-11-21**]- no growth to date
Images:
Chest Xray [**2200-11-21**]- The heart size is normal. The mediastinal
and hilar contours are within normal limits. The lungs are clear
without focal consolidation. No pleural effusion or pneumothorax
is visualized. There are no acute osseous abnormalities.
IMPRESSION: No acute cardiopulmonary process.
Chest PA/Lat [**2200-11-22**]- 1. Stable cardiac and mediastinal
contours. Patchy opacity at the right base is again seen, may
represent an early pneumonia or patchy atelectasis. Clinical
correlation is advised. The left lung is clear. No pleural
effusions or pneumothoraces. No acute bony abnormality.
Discharge labs
[**2200-11-24**] 06:45AM BLOOD WBC-6.0 RBC-3.86* Hgb-11.3* Hct-34.6*
MCV-90 MCH-29.3 MCHC-32.7 RDW-13.7 Plt Ct-177
[**2200-11-24**] 06:45AM BLOOD Neuts-61.7 Lymphs-31.7 Monos-4.2 Eos-1.8
Baso-0.5
[**2200-11-24**] 06:45AM BLOOD Glucose-89 UreaN-10 Creat-0.4 Na-142
K-3.8 Cl-108 HCO3-27 AnGap-11
[**2200-11-24**] 06:45AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
Brief Hospital Course:
Ms [**Known lastname 23328**] (goes by [**Female First Name (un) 33673**]) is a 25yoF with h/o asthma, anxiety,
HCV, who presents with acute asthmatic exacerbation. Briefly
admitted to the ICU, did not require intubation or NIPPV
.
# Asthma exacerbation: Diffuse wheezing, poor air movement, and
peripheral eosinophilia was suggestive of an acute asthmatic
exacerbation, likely in the setting CAP per CXR results. Initial
peak flow was less than 200, suggestive of severe obstruction.
She was briefly in the MICU on q3 duonebs for control. She was
started on systemic steroids. Did not require intubation or
NIPPV. CXRs suggestive of CAP so 5 day course azithromycin was
started. She was transferred to the floor after 1 day.
Management with a combination of inhaled bronchodilator therapy,
systemic glucocorticoids, and Z-pack. Fluticasone 2 puffs [**Hospital1 **]
was started. Peak flow improved to 350 standing. She contined to
have a nebulizer and O2 requirement until the morning of
discharge. Smoking cessation counselling was provided. She will
f/u in the [**Hospital1 18**] asthma clinic. She will complete Z-pack, and
take a 10 day course of prednisone. She should have outpatient
PFTs.
.
# Anxiety: continued home trazadone and gabapentin
.
# Hepatitis C: untreated to date but per pt pursuing treatment
options at [**Hospital1 2177**]
.
# Transitional issues:
- blood cultures pending
- Fluticasone started
- Finish azithromycin x 5 days ending [**2200-11-26**]
- Should get PFTs in outpatient setting
- Will follow up in [**Hospital1 18**] asthma clinic...needs a good asthma
action plan.
- Will finish 10 day course of prednisone
Medications on Admission:
- Celexa 20mg PO daily
- Trazodone 50mg PO daily
- Neurontin 300mg [**Hospital1 **]
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
3. fluticasone 220 mcg/actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
4. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
19 days: Please take five tablets for three days, then four
tablets for three days, then three tablets for three days, then
two tablets for three days, then two tablets for three days,
then one tablet for three days, then one-half tablet for four
days.
Disp:*47 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for an asthma exacerbation. You were given
steroids and nebulizers and you improved. Your chest x-ray was
concerning for a pneumonia so you were started on azithromycin.
You should continue to take your medications as prescribed.
Your medication changes include:
1. Continue prednisone as prescribed. This will be a very slow
taper.
2. Continue Azithromycin 250 mg tablets for two more days then
stop.
3. Continue Fluticasone inhaler. This is a steroid inhaler. One
puff twice a day.
4. Please continue albuterol inhaler, taking one to two puffs as
needed for shortness of breath.
***If you find yourself using more albuterol than you were using
in the hospital or with increasing shortness of breath, you
should call your doctor immediately or call 911 for further
assistance.
***We will provide you with a peak flow meter. You goal peak
flow for your height is approximately 450. If your peak flow
falls below 220, you should call your doctor or 911 for further
guidance.***
Followup Instructions:
Name: Dr [**First Name8 (NamePattern2) 2127**] [**Last Name (NamePattern1) **] (works with Dr [**Last Name (STitle) **]
Address: [**Hospital Ward Name 92607**], [**Location (un) **],[**Numeric Identifier 92608**]
Phone: [**Telephone/Fax (1) 11463**]
Appt: Thursday [**11-27**] at 3:30pm
NOTE: Dr [**Last Name (STitle) **] is your Primary Care doctor [**First Name (Titles) **] [**Last Name (Titles) 2177**]. He is also a
resident doctor. Dr [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 92609**] over sees this doctor and
thus both will be involved in your care. You will need to call
your insurance company and name Dr [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 92609**] as your
Primary Care Physician. [**Name10 (NameIs) **] MUST BE DONE ASAP.
It is recommended you follow up with a Pulmonologist for your
asthma condition. Please work with your PCP for [**Name Initial (PRE) **] referral to
one at [**Hospital1 2177**].
|
[
"300.00",
"493.92",
"305.1",
"288.60",
"070.54",
"799.02",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7728, 7734
|
4955, 6303
|
337, 343
|
7798, 7798
|
3656, 3656
|
8971, 9947
|
2399, 2423
|
6734, 7705
|
7755, 7777
|
6625, 6711
|
7949, 8948
|
2463, 3087
|
268, 299
|
371, 2150
|
3672, 4932
|
7813, 7925
|
6326, 6599
|
2172, 2237
|
2253, 2383
|
3112, 3637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,406
| 193,135
|
28049+28050
|
Discharge summary
|
report+report
|
Admission Date: [**2179-10-24**] Discharge Date: [**2179-11-15**]
Date of Birth: [**2136-9-16**] Sex: M
Service:
RESIDENT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RES
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33888**].
INTRODUCTION: [**Name6 (MD) 68265**] [**Name8 (MD) 61213**], [**Initials (NamePattern5) **]
[**Last Name (NamePattern5) **] [**Last Name (NamePattern1) **].
SERVICE: Trauma service.
CONSULTATIONS: Neurosurgery.
Orthopedic surgery.
Orthopedic spine surgery.
Plastic and reconstructive surgery.
Social work.
Hematology and oncology.
PROCEDURE: [**2179-11-13**], right hand laceration exploration with
right fourth finger extensor mechanism repair and right fifth
finger repair with complex wound closure.
[**2179-11-12**], right femoral inferior vena cava filter, Titanium
[**Location (un) 260**] placed.
HISTORY/PHYSICAL EXAM: The patient is a 48 year-old male who
was run over by an SUV and pinned underneath on his chest and
belly on [**2179-10-24**] outside of a night club in [**Hospital1 6687**]. He had
tire tracks to his chest. He had a basilar skull fracture,
multiple rib fractures. He had blood at his urethral meatus.
Occult blood was positive. He had labile blood pressures in
the 180's/80's. He was saturating 70% on non rebreather.
Initial hemoglobin on transfer was 37.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Stent placed 5 years ago in [**Location (un) 30285**],
[**State 33977**]. The patient does have coronary artery disease.
ALLERGIES: Unknown.
SOCIAL HISTORY: The patient denies alcohol or drug use. The
patient works as a bouncer at a night club in [**Hospital1 6687**].
MEDICATIONS: On beta blocker.
PHYSICAL EXAMINATION: Initial vital signs revealed 183/105;
128 heart rate; temperature 97.9; 18 respiratory rate;
saturating 79% on room air. Patient was intubated initially
when brought to the hospital. HEENT: Pupils were 3 mm, equal
and fixed. Large left occipital scalp laceration. Patient
had a right thigh laceration. He had multiple rib fractures
and ecchymosis over his right side. The patient had pain in
his pelvis. The patient had his right hand laceration with
weakness and extension of his right fourth and fifth fingers.
He also had apparently complained of back pain.
Cardiovascular: He has tachycardia, normal S1 and S2, no
murmur, rub or gallop. Respirations: Equal breath sounds
bilaterally. Abdomen was soft, nontender, nondistended.
Pelvis was unstable with AP and lateral compression. Tire
marks were across abdomen. Extremities: He had small
abrasions to his right chin. He was intubated.
Genitourinary: Positive blood at his urethral meatus. 1900 cc
of blood prior to transfer to [**Hospital1 **]. The
patient had a right chest tube placed which initially put out
200 cc of blood.
LABORATORY DATA: The patient's admit labs on [**2179-10-24**] showed
a white blood cell count of 23.7; hemoglobin of 12.3;
hematocrit of 36.6. Platelets 292. His white blood cell count
and his hemogram were followed throughout the course of his
stay with daily hemoglobins and hematocrits. The patient also
had daily coagulation factors and chemistries checked
throughout stay. His white count trended down to 14.5 on
[**2179-10-28**] before it peaked to 32.3 on [**2179-10-30**]. It stayed
elevated until [**2179-11-3**] at which time it was 28.0 and then
steadily trended down until at discharge it was 9.7 on
[**2179-11-14**]. His hematocrit was initially 36.6. On [**2179-10-28**], it
was 22.8 at which time he received a blood transfusion. It
trended down again until it was 22.4 on [**2179-11-2**]. He
received a transfusion and it was 30.8 on [**2179-11-4**] and on
discharge it was 26.9. His platelet count remained fairly
steady until on admission of 292 and [**11-3**] 480, remained
elevated at 546 upon discharge. The patient's coagulation
factors were monitored throughout the course of stay. On
admission, his PT was 1.9, PTT 22.0, INR of 1.0 on [**2179-10-27**],
one day after pulmonary embolism. The patient was started on
heparin. His INR was 94.3. This was maintained until Lovenox
was started at 100 mg b.i.d. Coumadin was begun and INRs
were monitored. INRs steadily crept up until 2.2 on
[**2179-11-15**]. On discharge, his total counts were PT of 22.1, PTT
of 35.0 and INR of 2.2. His differentials were [**2179-10-26**].
Neutrophils were 84%, lymphocytes were 11.2, monocytes 3.2,
eosinophils 0.8, basophils 0.3. D-Dymers were also measured
on [**2179-10-26**]; fibrinogen level was 705; D-Dymer level was
8083. He also had other tests. On [**2179-10-27**], his anti-
thrombin 3 level was 86. His protein C was 102; protein S was
67; his anticardiolipin antibody IGG was 5.8; his
anticardiolipin or ACA IGM was 7.6 and on [**2179-11-9**], his lupus
anticoagulant was negative. He also had his chemistries
monitored throughout his course of stay. On admission,
[**2179-10-24**], his sodium was 139; potassium was 3.6; chloride 104;
HC03 26; anion gap of 13; BUN of 15; creatinine of 0.8 and
glucose of 351. His blood glucose was measured throughout the
course of stay. He was treated with insulin and he had a
labile course of sugar readings throughout, ranging from 53
to 400. [**Last Name (un) **] was consulted and followed the patient
throughout the course of stay and management of his blood
sugars. His electrolytes remained fairly normal with the
exception of an increasing creatinine on [**2179-10-29**] to 1.3.
The rest of his labs were within normal limits. On
discharge, his final counts were sodium of 135, potassium of
4.2, chloride 102, HC03 24, BUN 16, creatinine 0.7 and
glucose of 175. On [**2179-10-25**], his CPK was measured at 1146.
His initial amylase on [**2179-10-24**] was 85. Otherwise, his CPK
levels trended down until [**2179-10-27**] which was measured at 372.
His cardiac enzymes, troponin T numbers from [**10-25**] and [**10-27**]
were 0.2 and less than 0.1, less than 0.1, less than 0.1.
His CK MB was 5,4,3,1 and 2 on [**10-25**] through [**10-27**]. Calcium,
mag and phos were also measured throughout his course of
stay. On admission, [**2179-10-24**], they were 8.5, 4.4 and 1.9
respectively. They were repleted as needed when magnesium was
less than 2. On [**2179-10-26**], his phosphorus was 1.9 and his
magnesium was 2.7. Phosphorus was repleted. On discharge,
his calcium was 9.2; phosphorus 3.8; magnesium 1.9. His
arterial blood gases were measured throughout the course of
stay, especially when he was in the intensive care unit.
While the patient was intubated, his initial blood gas on
admission was 7.21, 52, 60, 25 and -5. These numbers
represent pH, P02, PC02, HC03 and base excess. His initial
blood lactate on admission was 2.1 and trended down
throughout the course of stay. It was 0.9 on [**2179-11-1**].
Patient also had factor 5 [**Location (un) 5244**] and prothrombin mutations
pending at discharge. Patient had urinalysis which on [**2179-10-24**]
showed a large amount of blood, pH of 5.0, glucose of 1000
and ketones 15. Otherwise, patient had a urinalysis on
[**2179-10-30**] which showed a large amount of blood, urobilinogen
of 8, otherwise negative except for trace leukocytes and
trace protein. On [**2179-11-12**], his urinalysis was 6.5 pH,
urobilinogen 4 and otherwise negative. The patient did have
microbiology results. MRSA screen on [**2179-10-24**] was positive for
Staph aureus, coag positive. He had a sputum on [**10-25**] which
was gram stain and respiratory culture negative. On [**10-26**],
urine culture was negative. On [**10-26**], his gonococcal swab
was negative. On [**2179-10-26**], his chlamydia lab was negative
from his urine. The patient had a gram stain of his sputum on
[**2179-10-29**] which was negative and culture negative. On
[**2179-10-30**], blood cultures were negative x4 and negative on
[**10-30**]. Urine culture was no growth to date.
TO BE CONTINUED LATER WITH AN ADDENDUM
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Name8 (MD) 68266**]
MEDQUIST36
D: [**2179-11-15**] 15:03:31
T: [**2179-11-15**] 16:45:25
Job#: [**Job Number 68267**]
Unit No: [**Numeric Identifier 68268**]
Admission Date: [**2179-10-24**]
Discharge Date: [**2179-11-15**]
Date of Birth: [**2136-9-16**]
Sex: M
Service: TRA
ADDENDUM: This is continued discharge summary dictation.
DIAGNOSTIC STUDIES: [**2179-10-24**]: The patient trauma x-
rays PA and pelvis which showed multiple rib fractures on the
right and anterior pneumothoraces right greater than left,
bilateral basilar opacities that could be pulmonary
contusions and atelectasis, pneumomediastinum, endotracheal
tube and NG tube in standard position. CT recommended.
On [**2179-10-24**] CT of the head without contrast showed no
acute hemorrhage or fractures. Blood was within the maxillary
sinuses and nasopharynx, status post right temporal
craniectomy and a large left parietal scalp laceration.
On [**2179-10-24**] CT of the C-spine without contrast showed
pneumomediastinum, but no acute cervical spine fractures or
dislocations identified.
CT of the chest with contrast on [**2179-10-24**] shows
peritoneal air, mediastinal air, right anterior diaphragmatic
defect, bilateral pneumothoraces, multiple rib fractures on
the right, and spinous process fractures of T3, T4 and T5.
Also, a T10 chip fracture with slight anterior widening of
the vertebral body at this site, ligamentous injury
suspected. MRI recommended. Also, a left adrenal probable
adenoma not completely characterized by CT. Have a CT of the
chest, abdomen and pelvis.
On [**2179-10-24**] wrist films show a hamate fracture with a
dorsally displaced fragment of the right hamate bone.
Echo on [**2179-10-24**] shows left ventricular wall
thicknesses and cavity size are normal, basal half of the
inferior sputum and anterolateral walls contract well, and
free wall motion is normal, trivial pericardial effusion
noted.
On [**2179-10-25**] portable chest x-ray shows right chest
tube. This was done secondary to desaturation and chest tube
manipulation. Shows a slightly more peripheral oriented chest
tube. Also, a right paramediastinal density; could be
atelectasis, pneumonia or secondary to chest tube
manipulation. Continue followup recommended.
On [**2179-10-26**] shows resolved pneumomediastinum and no
pneumothorax on the right side.
On [**2179-10-25**] an EKG was performed which was sinus
rhythm at 75, a right bundle branch block, possible prior
inferior myocardial infarction. QTc was 477.
On [**2179-10-26**] the patient was to evaluate for possible
pneumonia or pulmonary contusion. There was slight worsening
of the left perihilar haziness which could have been due to
edema or aspiration, and the rib fractures were unchanged.
The patient had a CT of the upper extremity without contrast
on [**2179-10-26**] showing a triangular radiopaque foreign
body in the dorsal soft tissues of the wrist associated with
soft tissue swelling and laceration. Represents probable
piece of glass. No evidence of wrist fracture.
On [**2179-10-27**] CTA of the chest with and without
contrast and with reconstructions show:
1. Large pulmonary embolism in the left main, upper and
lower pulmonary arteries extending into the lower lobe
segmental arteries.
2. Small right pneumothorax, resolved left pneumothorax.
3. Patchy opacities within the right lung that could
represent contusion or aspiration.
4. New left pleural effusion, stable small pericardial
effusion.
5. Multiple fractures as noted on previous studies.
6. Left adrenal adenoma.
7. Low attenuation in the spleen, likely a benign finding
such as hemangioma.
8. Resolved pneumomediastinum.
On [**2179-10-27**] bilateral lower extremity vein ultrasound
shows no DVT.
Multiple chest x-rays were taken over the course of the next
few days; of which no visible pneumothorax was seen.
On [**2179-10-30**] MRI of the T-spine without contrast shows
signal changes in the anterior aspect of the T10 vertebral
body and T9-T10 intervertebral disc indicative of trauma at
this level with disruption of the anterior longitudinal
ligament. No evidence of widening in the interspinous
distance seen to indicate rupture of the ligamentum flavum or
posterior longitudinal ligaments. No evidence of intraspinal
hematoma were seen.
Multiple chest x-rays were taken between [**10-31**] to
[**11-6**] to evaluate the patient's status regarding his
fluid balance state as the patient had difficulty with
pulmonary edema. The last of which -- on [**11-6**] -- showed
resolving pulmonary edema, and marked improvement in the
edema, and normalization of fluid balance, residual
contusions were still seen laterally in the left lower lobe,
and rib fractures were continued to be noted.
The patient was post central line placement on [**2179-11-7**] showing no pneumothorax, and the tip of the catheter was
placed appropriately over the lower SVC.
On [**2179-11-9**] the patient had a chest x-ray showing
improving pulmonary edema and marked improved aeration in the
left lung.
The patient had a KUB of his abdomen on [**2179-11-11**]
which showed no evidence of an IVC filter. Otherwise, normal
abdomen.
On [**2179-11-10**] the patient had bilateral lower extremity
ultrasounds which showed no evidence of DVT; and it showed
patent femoral, superficial femoral and popliteal veins in
preparation for an IVC filter placement.
Also noted on [**2179-11-2**] was a bedside swallow study
which showed no signs of aspiration and functional oral and
pharyngeal swallowing.
HOSPITAL COURSE: The patient was admitted from the emergency
department to the trauma SICU. The patient remained intubated
once in the SICU. Studies were done as above. Orthopaedic
surgery was consulted in addition to orthopaedic spine
surgery. In addition to plastic surgery for the patient's
hand.
On [**2179-10-24**] a bronchoscopy was performed which allowed
clear visualization and showed no evidence of intratracheal
or intrapulmonary injury. EGD was also performed; and the
stomach, esophagus and oropharynx were clearly visualized
without any evidence of hemorrhage or luminal compromise.
There was no gastric injury noted. The patient's head
laceration was sutured on [**2179-10-24**] in addition to the
laceration on the right thigh. Two 3-0 Vicryl sutures were
used to reapproximate the deep tissue, and then the wound was
opposed with five 3-0 Nylon vertical mattress sutures. No
complications. No blood loss. No dressing was applied.
Neurosurgery was also consulted. The patient was started on
Protonix and maintained throughout his course of stay. While
intubated the patient's sedation was controlled with fentanyl
and propofol sliding scales to sedation. His right femoral
line was discontinued on [**2179-10-24**]. Chest tube output
was monitored. The patient remained ventilated on assist
control 40% with a PEEP of 12. The patient's blood pressure
was controlled with a wide range of medications, including
enalapril.
On [**2179-10-24**] on admission to the ICU the patient was
noted to have 2 peripheral IV's. He had propofol running and
intubated with endotracheal tube. He had a chest tube on the
right side to low continuous wall suction. He had a cervical
collar. He was on logroll precautions. The bronchoscopy and
endoscopy were performed as above. His neurological exam;
unable to assess orientation, spontaneous movement in all
extremities, followed simple verbal commands. Pupils were
equal and reactive to light and accommodation, sluggish, 2-
to 3-mm bilaterally, responded to pain and light touch.
Fentanyl and propofol were at 50 mcg an hour for sedation.
The patient's respiratory status was monitored. The patient
was noted to be obese and was noted to be a diabetic. While
in ICU, the patient was followed by the respiratory therapy
for control of vent settings.
As stated previously, plastic surgery was consulted for his
hand. A volar splint was applied on [**2179-10-25**] and the
arterial line was moved from right to his left upper
extremity secondary to injury. Surgery was planned for in the
future. On [**2179-10-25**] ortho spine was consulted; and MRI
was recommended to assess further damage to the T9-T10
injury. MRI was obtained and studies were as above. A TLSO
brace was recommended, and followup was recommended after
discharge with Dr. [**Last Name (STitle) 363**]. On [**2179-10-25**] multiple
weaning attempts were made; and the patient was unable to be
extubated. The right radial A-line was discontinued secondary
to the wrist fracture and moved to the left. The chest tube
was repositioned. X-rays were taken. Insulin GTT was
discontinued and a tight insulin sliding scale was started.
EKG on left and right sides were also performed and showed
right bundle branch block. Cardiac enzymes were sent.
On [**2179-10-26**] a sputum culture showed 3+ gram-positive
cocci and 2+ gram-positive rods. Chest x-rays were monitored
throughout course of stay in ICU. Please note earlier that
the spine attending was not Dr. [**Last Name (STitle) 363**], it was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1352**]. Clinical nutrition was consulted and followed the
patient throughout course of stay in ICU on [**2179-10-26**]
and helped the team managing the patient's tube feeds to
prevent over-feeding. Recommendations were followed. On
[**2179-10-26**] the patient was noted to be saturating to
88%. A chest x-ray was done, and the chest tube was placed to
water seal on a.m. rounds, and the patient was suctioned for
copious thick yellow secretions. The chest tube was placed
back to suction. A chest x-ray was done. Chest x-ray showed
no changes. Most likely the plug was thought to be causing
the desaturation. Later in the evening on [**2179-10-26**]
the patient had an acute desaturation which decreased into
the 70s. The patient was taken off the vent, and the patient
was then __________ on 100% FIO2. SPO2 was not increasing,
and the patient was easy to bag. Breath sounds were faint.
Airway was patent. An easy cap was placed on endotracheal
tube without color change, which was verified by the RN. The
endotracheal tube was pulled. Oral airway was placed, and the
patient was bagged via a mask. The patient had bilateral
breaths while __________, but SPO2 did not increase. An oral
endotracheal tube was placed by anesthesia and secured. A
code was called, which anesthesia had responded do and placed
oral endotracheal tube. Saturations remained at 40%.
Attending was in the room, and PEEP was increased to 20, 100%
FIO2. A chest x-ray was done and ABGs were sent. With a
questionable dislodged endotracheal tube, pulmonary embolus
or aspiration. Chest x-ray was clear, and a CTA of the chest
was ordered once the patient was stable. His EKG during this
time showed sinus tachycardia, and no significant changes
from prior EKG. Cardiac enzymes were pending, which ended up
eventually proving to be negative, and a CTA was ordered. The
CTA showed a large pulmonary embolism as noted above in
diagnostic studies section.
Occupational therapy was consulted on [**2179-10-27**] for
splint placement of the patient's right orthoplast splint.
They followed the patient throughout the course of stay. On
[**2179-10-27**] the patient had improved hypoxia. MGA's
records were obtained, and the patient was recommended to
have the MRI which showed a T9-T10 anterior longitudinal
ligament injury, and TLSO was recommended. Social work was
involved with the patient from [**2179-10-27**] and contact[**Name (NI) **]
the patient's mother and let her know the events. The
patient's mother was from [**State 5111**] and stayed at the
Holiday Inn in [**Location (un) 86**].
On [**2179-10-28**] after the pulmonary embolism was noted,
the patient was started on heparin GTT and monitored with
serial PT and PTT checks for treatment for pulmonary
embolism. Blood sugars were continued to be checked as above.
Bronchoscopy was performed on [**2179-10-29**]; and the
patient was suctioned with copious amounts of thick yellow
suctioned. No BAL was sent. The patient was tried to be
weaned off the vent but was unable to secondary to
desaturations. Breath sounds were coarse bilaterally.
Multiple chest x-rays were taken. Please see diagnostic
studies above.
On [**2179-10-30**] Levaquin was restarted after a sputum
culture sent when the patient spiked a temperature to 101.
The vent was weaned. CT was placed to water seal.
On [**2179-11-1**] secondary to large doses of heparin being
used to control the patient's PTT, heparin drip was turned
off and argatroban was started with a goal PTT of 50 to 70
and were monitored q.6h.. The patient's blood pressure would
increase to 200 to 220 systolic whenever was agitated.
Hydralazine, Lopressor IV, enalapril IV and labetalol drip
were used to control blood pressure; goal of 150 cc.
Pulmonary toilet was maintained, and sputum continued to
drain when the patient was turned from side-to-side. The
patient did note fluid around urethral meatus which was sent
gonococcal and Chlamydia studies. Please see above for
further details in laboratory data.
Over the course of the next 10 days the patient's respiratory
status waxed and waned with pulmonary edema and rounds of
Lasix IV were used to control this; and eventually Lasix 20
mg p.o. was used on the floor, and adequate fluid status was
maintained. The orthopaedic surgery team commented on the
patient's pubic rami fractures, and the decision was made to
treat these fractures nonoperatively. The patient had a left
inferior pubic rami fracture a right anterior pubic rami
fracture; also an L5 transverse process fracture, and
sacroiliac joint widening and T10 anterior endplate chip
fracture. All of these were decided to be treated
nonoperatively by the orthopaedic surgery service. The
patient was noted to be partial weightbearing on the right
lower extremity and full weightbearing on his left lower
extremity.
On [**2179-11-2**] the patient was extubated and tolerated
it well. A speech and swallow eval was done. The patient
passed without event and able to begin feeds. The patient
oriented to the hospital, the month, and the year. He
followed all commands, was pleasant, was moving all
extremities on the bed. No signs of aspiration were noted on
the speech and swallow study. Physical therapy was consulted
on [**2179-11-2**]; and based on weightbearing status as
above started therapy and followed the patient for remainder
of course; eventually getting the patient to ambulate using a
walker with an arm rail. By the end of the stay the patient
was able to ambulate on his own power.
The patient was transferred to the floor on [**2179-11-4**].
The patient was started on Coumadin 5 mg initially and INRs
were checked. The patient was maintained on telemetry for the
first 5 days while on the floor. The patient was noted to be
in sinus tachycardia. Metoprolol was increased with a
decrease in the heart rate; well controlled on metoprolol 100
t.i.d..
A PICC line was placed by IR on [**2179-11-5**] after the
patient lost IV access. The patient was tolerating a regular
diet on the floor. On [**2179-11-5**] orthopaedic surgery
signed off on the patient. The patient is to follow up with
Dr. [**Last Name (STitle) 1005**] in 4 weeks. In addition, ortho spine signed off
on the patient; and he was to continue the TLSO for 2 months.
Plastic surgery saw the patient on [**2179-11-6**] and
agreed to schedule surgery for the patient. The patient was
taken to the operating room on [**2179-11-8**] for right
extensor mechanism, right 4th finger extensor mechanism
repair. He was n.p.o. after midnight. IV fluids were started.
The patient underwent the procedure without problems. Please
see operative note for further details. [**Last Name (un) **] was consulted
on [**2179-11-8**] after the operation with plastic
secondary to elevated blood sugars up to 400 over the last
day. [**Last Name (un) **] followed the patient throughout the course of
stay and managed sliding-scale insulin. The patient
eventually stabilized on 45 units of Glargine at night and a
Humalog sliding scale. Coumadin had been held on the patient
for the 3 days prior to operation on [**2179-11-8**]. After
surgery on [**2179-11-8**] the patient was restarted on
Lovenox 100 mg b.i.d. in addition to being restarted on his
Coumadin. The patient tolerated the procedure with plastic
surgery well. Percocet and Dilaudid were used for
breakthrough pain. The patient's splint was placed on hand.
On [**2179-11-9**] hematology was consulted in regards to
the patient's hypercoagulability state. Labs were drawn to
work up for hypercoagulable state including protein C/protein
S anticoagulant, lupus anticoagulant, anticardiolipin
antibodies, IgG and IgM. These studies were negative and/or
within normal limits. Also, outpatient studies were done for
prothrombin [**Known lastname 1105**] gene mutation in addition to factor V Leiden;
which were pending upon discharge. The patient was set up
with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**] and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 68269**] for outpatient
hematology/oncology appointment in 4 to 6 weeks to follow up
on studies. The patient continued to improve at this point,
and INR was managed with Coumadin 5 to 10 mg daily until the
patient's discharge. On [**2179-11-15**] INR was 2.2 as the
patient had stabilized on 7.5 mg of Coumadin. The patient
remained afebrile, vital signs stable after transfer to the
floor.
On [**2179-11-12**]; however, the patient discussed with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of the trauma surgery service and the decision
was made to place an IVC filter. An ultrasound and KUB
ultrasound of his femoral veins showed patent vessels. In
addition, KUB showed no previous IVC filter was placed. The
patient was taken to the operating room on [**2179-11-12**].
There were no complications during the surgery; and IVC
filter was placed, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter, without problems
__________.
On [**2179-11-15**] -- day of discharge -- his right groin
suture from his IVC filter was taken out. His splint of his
right hand was taken off by plastic and orthopaedic surgery.
In addition, and orthoplast splint was made by occupational
therapy. The patient was discharged with no complaints in
stable condition with TLSO brace and outpatient follow-up
appointments given as needed. The patient was discharged to
home and plans to stay on [**Hospital1 6687**] for the next week, then
return to [**Location (un) 30285**], [**State 33977**] where he can be cared for by his
family.
DISCHARGE CONDITION: Good/stable.
DISPOSITION: The patient was discharged to home.
DISCHARGE INSTRUCTIONS: The patient was instructed to take
his Coumadin 7.5 mg daily. The patient will need to have his
INR checked on Thursday, [**11-18**]; a prescription has been
provided to the patient to present to a hospital for
outpatient blood draws. The results will be called into the
trauma center for adjustment of your Coumadin dose. The
patient was instructed to wear his TLSO brace at all times
when out of bed. The patient will need to be seen by a spine
surgeon in 4 weeks. If the patient is still in [**State 350**]
in 4 weeks, the patient is to follow up at [**Hospital1 346**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Otherwise,
the patient is to find a spinal surgeon in 4 weeks in
[**Location (un) 30285**], [**State 33977**]. The patient was also given instructions
regarding his insulin regimen, [**First Name8 (NamePattern2) **] [**Last Name (un) **]. The patient is to
call [**Last Name (un) **] at ([**Telephone/Fax (1) 17484**] if his fingerstick's run over
350 mg/dL. In addition, the patient was instructed on how to
administer the appropriate Humalog dosage by sliding scale.
If his fingerstick's were below 60 the patient was instructed
to drink a full glass of [**Location (un) 2452**] juice and then recheck his
fingerstick's. The patient has also signed a medical release
of information for a copy of your medical records to be sent
to [**Location (un) 30285**], [**State 33977**] to your sister's home address. The
patient expressed that he will seek medical care at one of
the area hospitals in [**Location (un) 30285**] once you arrive there. It is
important that the patient seek a primary care doctor [**First Name8 (NamePattern2) **]
[**Last Name (Titles) 30285**] once he arrives there. The patient was instructed
that he can be partial weightbearing on his right leg and
full weightbearing on his left leg. He was also instructed to
contact a physician or return to the emergency department for
a fever of greater than 100.8 degrees Fahrenheit, difficulty
breathing, increased pain or swelling of his right hand or
groin, chest pain, loss of consciousness or any other
concerns.
DISCHARGE DIAGNOSES: Please note now that earlier in the
course after discharge 8 that diagnosis is status post motor
vehicle crash; multiple rib fractures; left occipital scalp
laceration; right thigh laceration; right inferior pubic rami
fracture; left pubic inferior pubic rami fracture; L5
transverse process fracture; sacroiliac joint widening; T10
anterior endplate chip fracture; right 4th digit extensor
mechanism torn; right hamate fracture; T9-T10 anterior
longitudinal ligament injury; left pulmonary artery pulmonary
embolism, status post treatment.
DISCHARGE MEDICATIONS:
1. Warfarin 7.5 mg p.o. daily.
2. Percocet 5/325 one to 2 tablets p.o. q.4-6h. p.r.n. pain.
3. Metoprolol 100 mg p.o. t.i.d..
4. Enalapril 20 mg p.o. b.i.d..
5. Clonidine 0.1 mg per 24-hour patch applied weekly, every
Wednesday, transdermal.
6. Losartan 50 mg p.o. daily.
7. Hydrochlorothiazide 12.5 mg p.o. daily.
8. Rosiglitazone 4 mg p.o. b.i.d..
9. Lasix 20 mg p.o. daily.
10. Amlodipine 7.5 mg p.o. daily was given.
11. Docusate 100 mg p.o. b.i.d. was given as needed for
constipation.
12. Magnesium hydroxide 4 mg/5 mL suspension was given p.o.
q.6h. as needed for constipation.
13. Albuterol 90 mcg 2 puffs 4 times a day as needed for
shortness of breath or wheezing was given.
14. Glargine insulin 45 units at bedtime was given.
15. Humalog 100 unit/mL solution 1 dose subcutaneously 4
times a day as needed per sliding scale was given.
NOTE: Please note, the patient was also given a script for
outpatient lab work for PT and INR 1 to 2 times per week.
Also note, the patient was given a script for occupational
therapy and physical therapy. The patient was also given a
prescription for a Glucometer, insulin syringes, lancets and
test strips.
DISCHARGE FOLLOWUP: If the patient is still in [**State 350**]
please follow up with the Hand Clinic next Tuesday; call
([**Telephone/Fax (1) 2868**] to make an appointment in 4 weeks' time. If
you are still in [**State 350**] you should call to follow up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**], orthopaedic spinal surgeon; ([**Telephone/Fax (1) 68270**] for an appointment. The patient is also to follow up
with [**Last Name (un) **] Diabetes Center for ongoing diabetes teaching. An
appointment has been made for you in clinic at 1:30 today.
Please call [**Doctor First Name **], diabetes educator, at ([**Telephone/Fax (1) 17484**] to
reschedule if you need. Also, for any real issues related to
your hospital stay please call the Trauma Center by calling
([**Telephone/Fax (1) 6449**].
NOTE: Also please note, earlier in discharge summary under
procedures or operations that on [**2179-11-4**] a PICC line
was placed; and on [**11-15**] PICC line was removed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Name8 (MD) 68271**]
MEDQUIST36
D: [**2179-11-15**] 17:07:46
T: [**2179-11-15**] 20:12:26
Job#: [**Job Number 67423**]
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Discharge summary
|
report
|
Admission Date: [**2199-1-3**] Discharge Date: [**2199-1-15**]
Date of Birth: [**2131-1-21**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 67 year old left handed man with a history of
hypertension who presents after being found down in his
apartment with blood pressure 170/104 and a right
frontal-parietal IPH with bilateral subarachnoid extension. He
is
accompanied today by his brother [**Name (NI) **] and his sister [**Name (NI) **].
The patient is unable to give a history due to aphasia. His
brother, [**Name (NI) **], reports that he was called today because the
patient did not show up at work. Apparently early this morning
he was seen walking his dog, but may have been imbalanced. At
approximately 11 am, his neighbor heard him trying to call out,
moaning, and making noises from his apartment, so EMS was
called. He was found on the floor, awake and able to nod yes/no
to questions but unable to stand. He was brought to an OSH.
The patient was initially seen at [**Hospital1 **] where bp
164/116->170/104->174/100, HR 97, RR 20, SaO2 100% on 4L NC,
FSBG 90. Exam showed left sided facial weakness, garbled speech,
moving right side only, looks towards the right side, not able
to answer questions, able to attempt to follow commands such as
smiling. A hard collar was applied due to a question of neck
injury due to bruising. Head CT showed a right parietal IPH with
bilateral acute subarachnoid blood. CT C-spine showed mild
degenerative changes, no evidence of acute cervical spine
fracture or traumatic cervical malalignment. CXR showed
cardiomegaly. Labs showed WBC 10.9, Hct 48.8, plt 208, CK 138,
Na 141, K 3.9, Cl 3.9, Cl 101, CO2 24, glucose 83, BUN 23, Cr
1.3, Ca [**98**].1, Tbili 1.1, AST 24, ALT 19, INR 1.1, alk phos 72,
TropT 0.02. He was given Labetalol 10 mg IV, Decadron 10 mg IV,
Dilantin 1 gram IV, and Zofran 4 mg IV. He was transferred to
[**Hospital1 18**] for further evaluation.
Neurosurgery was consulted at [**Hospital1 18**] and recommended SBP
parameters <130, so he was started on Nicardipine gtt. CTA head
showed no aneurysm or major vascular malformation. Neurology was
consulted for further evaluation.
Past Medical History:
Hypertension
Raynaud's syndrome
Hearing impaired
Cataracts
Social History:
He lives with his dog. He works 3 days/week at a funeral Home in
[**Location (un) 2624**]. He previously smoked cigarettes but has since quit. He
drinks 3-4 shots of alcohol/day x10-20 years. His family does
not think he uses illicit drugs.
Family History:
His father and mother had hypertension. There is no family
history of stroke or IPH.
Physical Exam:
VS: temp 97.1, bp 135/75, HR 84, RR 16, SaO2 95% on 2L
Genl: Awake, alert
Neck: Hard C-collar in place
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen
Ext: Bruise on right hand and scratch on left shoulder
Neurologic examination:
Mental status: Awake and alert, intermittently agitated trying
to sit up in bed. Oriented to his first name only, not able to
name the place or date. Says yes/no but not always
appropriately, nonfluent aphasia, frustrated that cannot get out
the words he wants to say. Dysarthric. Unable to name any stroke
scale
objects, but is able to point to the feather and chair on the
stroke scale card (but unable to point to the other objects
correctly).
Cranial Nerves: Pupils equally round and reactive to light, 5 to
4 mm bilaterally. Decreased blink to threat on the left. Right
gaze preference, but is able to get past midline to the left
when tracking a dollar [**Doctor First Name **]. Appears to have difficulty with
upgaze on the right. Flat left NLF, and although he cannot
follow the command to keep his eyelids closed against
resistance, he does
appear to have his left eye opened wider than the right. Does
not follow command to protrude tongue.
Motor: Slightly decreased tone in his left arm, increased tone
in his bilateral legs. No observed myoclonus, but + postural
tremor in the right arm. Full strength in the right arm and leg
(muscle groups he cooperated with testing include deltoid,
triceps, biceps, WE, FF, IP, quadriceps, PF, and all were 5). He
does not withdraw his left arm to noxious stimulus, and triple
flexes his
left leg to noxious.
Sensation: He groans to nailbed pressure and pinch on his left
arm and leg.
Reflexes: 2+ and symmetric in biceps, brachioradialis, triceps.
3+ and symmetric in knees. 0 and symmetric in ankles. Toes
upgoing bilaterally.
Coordination: Deferred
Gait: Deferred
Pertinent Results:
[**2199-1-14**] 05:35AM BLOOD WBC-7.9 RBC-4.45* Hgb-14.3 Hct-41.3
MCV-93 MCH-32.2* MCHC-34.7 RDW-13.2 Plt Ct-257
[**2199-1-14**] 05:35AM BLOOD Glucose-106* UreaN-35* Creat-0.7 Na-145
K-3.8 Cl-108 HCO3-25 AnGap-16
[**2199-1-13**] 05:50AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.3
[**2199-1-4**] 02:33AM BLOOD %HbA1c-5.4 eAG-108
[**2199-1-4**] 02:33AM BLOOD Triglyc-45 HDL-109 CHOL/HD-2.1
LDLcalc-108
ECG: Normal sinus rhythm. Complete left bundle-branch block.
Compared to
tracing #1 no diagnostic interval change.
CTA head:
1. Large right frontal lobar hematoma with accompanying
subarachnoid
hemorrhage without midline shift or herniation. In this age
group, consider amyloid angiopathy. Underlying mass or vascular
malformation cannot be excluded.
2. Patent cerebral vessels without evidence of aneurysm greater
than 3 mm or dissection.
3. Age-related involution, small vessel ischemic disease, and
bilateral basal ganglia lacunes.
Video swallowgram:
Minimal penetration with thin liquids. Delayed swallow.
Brief Hospital Course:
The patient is a 67 year old left handed man with a history of
hypertension who presents after being found down in his
apartment with blood pressure 170/104 and a right
frontal-parietal IPH with bilateral subarachnoid extension. His
exam is significant for nonfluent aphasia, dysarthria, decreased
blink to threat on the left, right gaze preference but able to
look to the left, flat left NLF but also upper face weakness on
the left, does not withdraw his left arm to noxious, triple
flexes his left leg to noxious, upgoing toes bilaterally. He has
a right fronto-parietal IPH with likely subarachnoid extension.
Given the patient's left handedness, it is likely that his
language centers are on the right or at least bilateral given
that he does have some speech production (his name). The
etiology is likely hypertensive given his history and elevated
blood pressure upon admission to the OSH. CTA head does not show
an underlying vascular malformation.
HOSPITAL COURSE:
NEUROLOGY
Patient was admitted to the neuro ICU, exam remained stable.
Follow up CT on [**2199-1-4**] was stable. With story of being found
on the ground an aphasia a c spine CT was done which was
negative for any fracture. C-collar was cleared on [**1-4**].
His lipid panel showed elevated LDL hence he was started on
simvastatin 20mg once daily.
Additionally, patient underwent prolonged EtOH withdrawal during
this admission requiring Valium and Ativan PRN. At the time of
discharge, he was no longer having any withdrawal sypmtoms and
not requiring any benzodiazepines.
Cardiology:
Initially required nicardipine gtt but was able to be switched
to labetalol and he is discharged on 300mg twice daily. He can
be titrated upwards and/or 2nd [**Doctor Last Name 360**] added if needed.
Gastrointestinal / Nutrition:
Initially poor swallowing status but videoswallowing exam on
[**1-14**] [**Last Name (un) **] that he was swallowing with minimal penetration
hence he was started on ground solids, thin liquids and crushed
meds.
Disposition:
He was evaluated per physical and occupational therapists and he
is recommended for acute rehab. He is discharged to rehab and
will be following up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (neurology attending
who oversaw his care during this admission) as outpatient.
Medications on Admission:
Unclear
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day).
8. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for GI ppx.
10. labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for Htn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary diagnosis:
(432.9) Hemorrhagic stroke, etiology uncertain, but likely
related to chronic hypertension and possibly alcoholic
vasculitis as well
Secondary diagnoses:
-Chronic alchohol dependence
-Uncontrolled chronic hypertension
-Hypercholesterolemia
Discharge Condition:
Aphasic, speaks gibberish. Does not follow commands. Left
hemiparesis. Localizes noxious stimuli.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you had bleeding in your brain,
likely due to high blood pressure. You were treated for alcohol
withdrawal for several days with benzodiazepines (ativan and
valium.) You no longer require medication for alcohol
withdrawal. It is very important that you do not drink alcohol.
With rehab, we hope that your weakness and speech will improve
with time.
Followup Instructions:
(1) MRI appointment -- need to call [**Telephone/Fax (1) 327**](#1) to arrange
(MRI ordered in OMR). This MRI needs to be performed prior to
your appt with Dr. [**Last Name (STitle) **].
(2) With Dr. [**Last Name (STitle) **] in Neurology-Vascular (stroke) [**Hospital 702**]
clinic ([**Location (un) **] of [**Hospital Ward Name 23**] Clinical center @[**Hospital1 1426**]/[**Location (un) **]
Aves.):
TUESDAY, [**3-5**] at 2:30pm
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2199-1-15**]
|
[
"342.90",
"447.6",
"443.0",
"784.3",
"291.0",
"430",
"401.9",
"303.91",
"389.9",
"432.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9165, 9310
|
5928, 6886
|
314, 321
|
9613, 9713
|
4899, 5905
|
10160, 10716
|
2740, 2826
|
8306, 9142
|
9331, 9331
|
8274, 8283
|
6904, 8248
|
9737, 10137
|
2841, 3233
|
9505, 9592
|
264, 276
|
349, 2381
|
3721, 4880
|
9350, 9484
|
3272, 3705
|
3257, 3257
|
2403, 2464
|
2480, 2724
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,431
| 133,369
|
722
|
Discharge summary
|
report
|
Admission Date: [**2148-3-2**] Discharge Date: [**2148-3-7**]
Date of Birth: [**2070-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension/hypoxia
Major Surgical or Invasive Procedure:
Placement of Dobhoff tube
Placement of Arterial line
History of Present Illness:
77 yo M NH resident h/o schizophrenia, CAD, HTN, dementia p/w
hypoxia and FTT from NH. According to the NH records, pt had an
episode of desaturation to mid 80's on RA several days ago. He
came up to 91% on 2L NC. He was also noted to have decreased po
intake, eating only with assistance and only preferred foods.
IVF fluids were given. CXR at NH neg, UA pos. Started on
levaquin 500 mg po on [**2-29**], also given 1 dose of CTX.
Subsequently, ucx came back as < 10,000 organisms. As patient
continued to be hypotensive and hypoxic, he was transferred to
the [**Hospital1 18**].
According to NH note, the pt is mostly non-verbal, AAOx1. Pt was
able to nod yes or no in the ED and denied cough, diarrhea. +
SOB, + dizziness. He was unreponsive for other questions. On
evaluation in the ICU he was unresponsive.
In the ED, BP 85/65 initially, then 73/54. Other VS: HR 61, RR
22, O2Sat 100%NRB. He received a total of 2.9L. A foley was
placed and he urinated about 225cc. Pt received empiric
Vancomycin, Levaquin and FLagyl for possible aspiration PNA
although CXR showed no clear consolidation. UA was done and was
negative. An EKG was done an revealed SR, HR 80, NA, loss of RW
in inferior leads, V1, V2 and STE in V2 with overall low
voltage. CE were significant for Trop 0.14, CK 596, MB flat.
Cardiology was called, ekg was faxed: assessment - CE leak
likely demand, EKG with new anteroseptal q's from [**2133**] but no
clear ischemic changes currently. Recommended: Serial EKGs,
cycle CEs. Serial EKG showed no change.
Past Medical History:
Schizophrenia, per NH notes, baseline AAOx1, verbally abusive
Depression
HTN
Dementia
R eye cataract
CAD, sternotomy present, ? CABG, no documentation
Social History:
Unable to obtain
Family History:
Non-contributory
Physical Exam:
VS T 97.6 BP 88/49 HR 55 RR 20 O2Sat 98 RA, negative pulsus
paradoxus
Gen: NAD, non-verbal, opens eyes to voice, not following
commands
HEENT: NC/AT, PERRLA, arcus senilis, dry mm, evidence of thrush
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, mildly bradycardic, [**1-3**] holosystolic
murmur over apex, radiating into axilla
PULM: CTA b/l, no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, nt
Skin: cool extremities, tenting of skin, ulcer over L malleolus
with necrotic tissue and surrounding edema, Stage 2 Decubitus
ulcer
EXT: trace DP, no edema/c/c
Neuro: moving all extremities, withdrawing to pain, PERRLA,
reflexes 1+, downgoing Babinsky
On discharge, the patient was afebrile. His exam was largely
unchanged. His sacral and trocanteric decubuti were stable.
The ulcer over his left malleolus was also stable.
Pertinent Results:
[**2148-3-7**] 02:43AM BLOOD WBC-9.9 RBC-3.18* Hgb-9.9* Hct-29.2*
MCV-92 MCH-31.3 MCHC-34.1 RDW-14.3 Plt Ct-301
[**2148-3-2**] 04:03PM BLOOD Neuts-93.8* Bands-0 Lymphs-4.4*
Monos-1.7* Eos-0.1 Baso-0.1
[**2148-3-7**] 02:43AM BLOOD Plt Ct-301
[**2148-3-3**] 02:20AM BLOOD ESR-40*
[**2148-3-7**] 02:43AM BLOOD Glucose-113* UreaN-11 Creat-0.5 Na-142
K-3.6 Cl-110* HCO3-26 AnGap-10
[**2148-3-4**] 05:43AM BLOOD ALT-85* AST-40 LD(LDH)-173 AlkPhos-84
TotBili-0.3
[**2148-3-7**] 02:43AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1 Cholest-64
[**2148-3-3**] 02:20AM BLOOD CRP-60.0*
[**2148-3-7**] 02:43AM BLOOD Triglyc-43 HDL-26 CHOL/HD-2.5 LDLcalc-29
[**2148-3-2**] 10:25PM BLOOD Type-ART pO2-172* pCO2-37 pH-7.42
calTCO2-25 Base XS-0
CXR: FINDINGS: As compared to the previous radiograph, a new
Dobbhoff catheter has been inserted. The tip of the catheter
projects over the stomach. However, since the last examination,
a hiatal hernia with subsequent displacement of the part of the
stomach into the thorax becomes manifest. The tip of the
previously positioned nasogastric tube is now projecting into
the thorax. Otherwise, there are no major changes. Unchanged
size of the cardiac silhouette, subtle retrocardiac atelectasis.
The right basal parts of the lungs are slightly denser than on
the previous radiograph, but without evidence of focal
parenchymal consolidations.
EKG: Normal sinus rhythm. Q waves in leads V1-V2 suggestive of
prior anterior myocardial infarction. Low limb lead voltage.
Borderline left axis deviation.
Ankle xray: Three radiographs of the left ankle demonstrate
patchy, regional, demineralization about the ankle and foot. The
finding limits assessment for acute fracture or subtle cortical
fragmentation. No acute injury is identified. Osseous remodeling
about the distal metaphyses of the tibia and fibula may
represent the sequela of remote trauma. Assessment for the
presence and/or absence of subcutaneous emphysema is limited by
overlying dressing material. The mortise is congruent. The talar
dome contour is smooth. There is a plantar calcaneal spur.
Vascular calcifications are noted.
ECHO: The left atrium and right atrium are normal in cavity
size. There is mild symmetric left ventricular hypertrophy with
normal cavity size. There is mild to moderate regional left
ventricular systolic dysfunction with severe
hypokinesis/akinesis of the distal half of the anterior septum
and anterior walls and distal inferior wall. The apex is mildly
aneurysmal and dyskinetic. The remaining segments contract
normally (LVEF = 35-40 %). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
CTA Head and Neck:
IMPRESSION: No acute infarcts and no CT perfusion abnormalities.
Occlusion of the origin and proximal portion of the right
vertebral artery with reconstitution within the mid cervical
portion.
Brief Hospital Course:
77 year old male admitted to the hospital after having
desaturation to the mid-80's on room air, hypotension as well
decreased oral intake. On admission, the patient was
hypotensive, hypoxic with an elevated white count. He had an
infectious work up which was unrevealing. His urinanalysis was
negative, his various pressure sores did not appear infected.
His chest x-ray on admission was negative for acute infection.
He appeared severely dehydrated on exam. The patient received
intravenous fluids for his decreased hydration as well as for
his hypotension. He also received antibiotics initially given
his diarrhea and recent antibiotics course while at the nursing
home as well as given his elevated white count. He also
received one dose of fluconazole for oral thrush which did not
resolve with oral Nystatin. The patient had an x-ray of his
ankle to evaluate for osteomyelitis underlying his ulcer. The
xray did not appear consistent with osteomyelitis.
The patient had a NG tube placed for additional nutritional
support while in the hospital. He received tube feeds while in
the hospital. He was tolerating softs by mouth prior to
discharge. His NG tube was discontinued prior to discharge.
He also had both an EKG and echocardiogram which showed evidence
that the patient had a myocardial infarction prior to his
admission to the hospital. His EKG appears consistent with an
anterior MI. His ECHO demonstrated normal sized left and right
atrium with mild symmetric left ventricular hypertrophy with
normal cavity size. There was mild to moderate regional left
ventricular systolic dysfunction with severe
hypokinesis/akinesis of the distal half of the anterior septum,
anterior walls and distal inferior wall. The apex is mildly
aneurysmal and dyskinetic. The remaining segments contract
normally (LVEF = 35-40%).
During his hospital course, the patient appeared less responsive
with dysarthria and right sided weakness. He had a CT scan of
his head and neck vasculature, which is reported above. The
neurology team was consulted to evaluate the patient. They felt
he may have had a small TIA. He was continued on aspirin, an
increased dose of statin and Plavix. His cholesterol was
checked, which was within normal limits. He had a hemoglobin
A1C pending at discharge. His neurological symptoms had
resolved at the time of discharge.
Medications on Admission:
Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain, fever.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
Colace 1.5 g Suppository Sig: One (1) Rectal once a day as
needed for constipation.
Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day.
Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Mirtazapine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Fleet Enema PRN
MOM PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
6. Colace 1.5 g Suppository Sig: One (1) Rectal once a day as
needed for constipation.
7. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Shock, likely cardiogenic vs septic
Chronic decubiti ulcers
Thrush
Secondary:
Schizophrenia
Depression
Hypertension
Coronary Artery disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with low blood pressure and
low oxygen levels. While you were in the hospital you received
antibiotics for a possible pneumonia and treatment for a
possible gastrointestinal infection. Both of your antibiotics
were stopped as it does not appear that your stool or lungs are
infected.
It appears you had a small stroke, or TIA while you were in the
hospital. You have no residual problems from your small stroke.
We increased your statin.
It appears you may have had a heart attack prior to coming to
the hospital.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1266**]. The phone number is [**Telephone/Fax (1) 608**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"295.62",
"112.0",
"435.9",
"428.0",
"294.8",
"276.51",
"785.50",
"707.03",
"707.04",
"410.11",
"428.22",
"707.06",
"401.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10805, 10876
|
6337, 8708
|
340, 394
|
11069, 11078
|
3077, 6314
|
11680, 12024
|
2175, 2193
|
9714, 10782
|
10897, 11048
|
8734, 9691
|
11102, 11657
|
2208, 3058
|
281, 302
|
422, 1950
|
1972, 2125
|
2141, 2159
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,773
| 102,551
|
24545+57405
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-4-13**] Discharge Date: [**2140-4-22**]
Date of Birth: [**2062-11-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD and colonsocopy with gastric biopsy, [**2140-4-20**].
History of Present Illness:
77 y/o WF was was initially transferred from [**Hospital3 **]
[**4-13**] for descending thoracic and infrarenal aortic aneurysms
found after CTA done for severe chest/epigastric pain with
radiation to back. Initially there was concern for dissection.
Patient arrived to [**Hospital1 18**] with SBPs in low 200s and HR in 50s and
started on nipride drip. She had no other complaints except
epigastric tenderness on exam.
Past Medical History:
1. CVA/stroke-no deficits except memory and aphasia(uncertain
which side)
2. HTN
3. GERD
4. hypercholesterolemia
5. skin Cancer NOS
6. right hip fx
7. s/p TAH
9. 4.3 cm infrarenal AAA noted on CT [**2137**]
10. Recent (4-5 months ago)PNA 3 week stay at [**Hospital3 5365**],
details unknown.
11. ? Dementia
12. No cardiologist. No history of cath. Does not know of ETT in
past. Dr [**First Name (STitle) **] at [**Hospital1 392**] is PCP.
Social History:
Lives with husband at [**Hospital3 **]. Has a son, [**Name (NI) **], who
is very involved in her care.
Tob: Quit 10 years ago
EtOH: Social drinker.
Family History:
Non-contributory
Physical Exam:
VITALS: 97.3, 67(62-67), 111/69(111-154/70's), 97% 4L
GEN: NAD, [**Name (NI) 22031**], pt had difficulty sticking tongue out all the
way. OP clear with MMM. Neck Supple, no JVD, no bruit
appreciated.
CV: regular, nl s1s2, no murmurs
CHEST: Decreased breath sounds at bases. Isolated area of
wheezes on R, b/l rhonchi at bases more prominent on expiration.
ABD: Flat NT/ND NABS
Ext: No edema, 2+ pulses. Warm and well perfused. Full ROM all
ext with 5/5 strength.
Neuro: A+O x 3, Slow but apporiate response to all questions,
repeats answers, occasional word finding difficulties.
Pertinent Results:
[**2140-4-13**] 02:54PM LACTATE-2.0
[**2140-4-13**] 02:28AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2140-4-13**] 02:28AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2140-4-13**] 01:50AM UREA N-30* CREAT-1.1 SODIUM-138 POTASSIUM-4.2
CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
[**2140-4-13**] 01:50AM ALT(SGPT)-14 AST(SGOT)-18 CK(CPK)-76 ALK
PHOS-96 AMYLASE-71 TOT BILI-0.3
[**2140-4-13**] 01:50AM LIPASE-19
[**2140-4-13**] 01:50AM cTropnT-<0.01
[**2140-4-13**] 01:50AM CK-MB-2
[**2140-4-13**] 01:50AM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2140-4-13**] 01:35AM WBC-12.1* RBC-4.60 HGB-13.1 HCT-39.2 MCV-85
MCH-28.4 MCHC-33.4 RDW-13.5
[**2140-4-13**] 01:35AM NEUTS-62.6 BANDS-0 LYMPHS-30.9 MONOS-3.7
EOS-2.3 BASOS-0.6
[**2140-4-13**] 01:35AM PLT COUNT-250
[**2140-4-13**] 01:35AM PT-12.3 PTT-30.1 INR(PT)-1.0
CTA [**2140-4-13**]: IMPRESSION: Penetrating ulceration and aneurysmal
dilatation of the descending thoracic aorta, with areas of
intramural hematoma in the thoracic aorta. The areas of
penetrating ulceration continue into the upper abdominal aorta,
with a 3.7 cm infrarenal abdominal aortic aneurysm as described.
CXR [**2140-4-14**]: There is widening of the mediastinum, which has a
slightly ill- defined margin. While this may be positional,
there are no prior radiographs for comparison. Given that the
recent CT scan, performed yesterday demonstrated an aortic ulcer
with intramural hematoma and that there is a new left pleural
fluid collection, clinical correlation and followup CT scan are
recommended.
CXR [**2140-4-15**]: Left lower lobe pneumonia versus atelectasis.
CXR [**2140-4-16**]:
There is continued marked tortuosity of the thoracic aorta.
Please refer to recent CT scan report.There is continued left
lower lobe consolidation most likely indicating atelectasis. The
possibility of pneumonia cannot be excluded. There is continued
small left pleural effusion. The lungs are clear otherwise. The
heart is normal in size. No pneumothorax is seen.
CXR [**2140-4-17**]: Mild congestive heart failure with cardiomegaly and
small bilateral pleural effusion.
ECHO [**2140-4-20**]: Mild symmetric left ventricular systolic function
with preserved global and regional biventricular systolic
function. Mild mitral regurgitation.
Based on [**2131**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a low risk (prophylaxis not recommended).
Clinical decisions regarding the need for prophylaxis should be
based on clinical and echocardiographic data.
CULTURE RESULTS:
URINE CULTURE (Final [**2140-4-17**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
PRESUMPTIVE STREPTOCOCCUS BOVIS. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood and sputum Cx's neg.
Brief Hospital Course:
1. Abdominal pain. This is a 77 F with history of HTN, AAA, and
CVA who presented with acute onset of abdominal pain on [**4-13**].
The patient was initially admitted to Vascular surgery service.
CT done at OSH was concerning for aortic dissection. Upon
further evaluation of images and comparison with [**2137**] studies,
it was found that descending aortic aneurysm was unchanged from
2 years ago and there was no dissection. On CT done at [**Hospital1 18**] AAA
size was measured 3.7 cm. Her abdominal pain resolved without
intervention soon after transfer. CT did show that she had
several large gallstones within the gallbladder. There was no
evidence of acute cholecystitis. Possible etiologies of her
abdominal pain included passing of a gallstone or gastritis
(later confirmed on EGD). LFT's were WNL on admission. The
patient was continued on PPI during this admission. She remained
asymptomatic and was tolerating po's well.
2. UTI. On [**4-14**], the patient developed T 102 with UCx positive
for E. coli >100,000 and Strep bovis in urine. She was started
empirically on a 3-day course of Bactrim.
She was then continued on a 7-day course of Levaquin per ID
because of better coverage of Strep bovis with Levaquin and also
because of CXR finding concerning of pneumonia. Would recommend
repeating UA and culture after she completes treatment course to
ensure resolution.
3. Atrial fibrillation, new diagnosis. [**4-16**] the patient was
found with new onset Afib with rapid ventricular response
130-150 with decrease in BP (SBP from 130 to mid 80s for 3
minutes). IV Lopressor was given without success and she was
loaded with IV amiodarone with subsequent return to NSR.
Cardiology were consulted. Cardiology consultants advised to
continue amiodarone po loading followed by 400 mg po bid dose x
7 days then 200 mg po daily. Vascular surgery were reconsulted
with question of anticoagulation in the setting of AAA and
advised that AAA is not a contraindication to anticoagulation.
The patient was started on anticoagulation with unfractionated
heparin while in the hospital in anticipation of colonoscopy.
After EGD/colonoscopy, she was then started on lower dose
Coumadin, 3 mg daily, (as she was also on Levaquin and
Amiodarone). Given history of a prior stroke which puts her at a
high risk for thromboembolic events, it was felt that the
patient needs to be bridged with Heparin to overlap with
therapeutic INR x 2days. Prior to discharge, the patient's son
learned to do Lovenox injections. Her INR was 1.3 on the day of
discharge (goal [**12-24**]). Dr. [**Last Name (STitle) 4541**] will be the patient's outside
cardiologist. Dr.[**Name (NI) 54594**] office was contact[**Name (NI) **] and they will
follow [**Name (NI) 62023**]. The patient was in sinus for the remained of her
hospitalization. Cardiology consultants recommended that the
patient will absolutely need continuous loop recorder after her
discharge. A close f/u appointment with Dr. [**Last Name (STitle) 4541**] was arranged
for the patient. Of note, the patient's TSH and free T4 were
checked and were 1.1 and 1.3 respectively. The patient did have
an echocardiogram during this admission which showed normal EF,
symmetric LVH and mild MR. There was no evidence of intracardiac
thrombi.
4. H/o prior embolic stroke. The patient was continued on low
dose aspirin.
5. AAA. Stable, 3.7 cm. The patient needs tight BP control. Goal
SBP <130.
6. HTN. The patient was continued on Lopressor, Imdur, and
Lisinopril. She had severe HTN with SBP in 200's requiring doses
of IV Hydralazine. Lopressor and Lisinopril were titrated up.
The patient c/o increased cough during this admission and an ACE
inhibitor was later changed to [**First Name8 (NamePattern2) **] [**Last Name (un) **] to eliminate it as a cause
of her cough. (the patient was on a low dose Prinivil as an
outpatient). Her BP medications will likely need further
adjustment as an outpatient.
7. Anemia. Iron studies revealed low serum Fe/TIBC ratio, but
Ferritin was >500. B12 level was also low, 230. The patient was
started on Vitamin B12 supplements and was continued on iron
supplements. Given suspicion for iron deficiency anemia and need
for chronic anticoagulation as well as finding of Strep bovis in
urine, GI were consulted and the patient underwent EGD and
colonoscopy which were significant for gastritis and diverticuli
in duodenum and sigmoid but showed no evidence of malignancy in
colon. Stomach biopsy was done and the results are pending at
the time of this discharge. GI recommended capsule endoscopy as
an outpatient and this was scheduled for [**2140-4-29**].
Instructions regarding bowel prep were communicated to the
patient's son.
8. Pulmonary. The patient was on inhalers including steroids as
an outpatient. The was no h/o COPD documented. She did not have
evidence of bronchospasm and her only pulmonary complaint during
this admission was cough, which could have been due to a
respiratory infection, post-nasal drip or ? ACE side effect. CXR
intially showed evidence of CH which improved clinically
throughout her admission. The patient was continued on Lasix 20
mg po daily. ACE was stopped to eliminate this as cause for
cough. The patient was on Levaquin for UTI which will also cover
a pulmonary source. Clinically her cough was not worse at night.
She was told to resume her outpatient inhalers and to continue
with a nasal spray. She will follow up with her PCP.
11. Hypercholesterolemia. She was continued on Pravachol
12. Code: FULL
Medications on Admission:
Meds On Admission:
Protonix 40 mg po qd
Actonel 35 mg po q week
Albuterol 2 puffs q4 hrs prn
[**Doctor First Name **] [**Hospital1 **]
ASA 81 mg po daily
Ferrous sulfate 325 mg
Flonase
Flovent 2 puffs [**Hospital1 **]
Lasix 20 mg daily
Imdur 30 mg po daily
Lopressor 75 mg po bid
Os-Cal 500 mg [**Hospital1 **]
Pravachol 40 mg po qd
Prinivil 2.5 mg po qd
Zetia 10 mg po qd
Cipro (recently completed a 5 day course)
MEDS on transfer:
Isosorbide Dinitrate 20 mg PO TID
Lisinopril 10 mg PO DAILY
Acetaminophen 325-650 mg PO Q4-6H:PRN
Metoprolol 100 mg PO TID
Pantoprazole 40 mg PO Q24H
Dolasetron Mesylate 12.5-25 mg IV Q8H:PRN nausea
Furosemide 20 mg PO DAILY
HydrALAZINE HCl 10 mg IV Q4H
Sulfameth/Trimethoprim DS 1 TAB PO
Amiodarone
Discharge Medications:
1. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1)
Subcutaneous Q24H (every 24 hours) for 4 days: Please consult
Dr. [**Last Name (STitle) 4541**] after you have INR checked on Monday if you need to
continue Lovenox.
Disp:*4 pre-filled syringes* Refills:*0*
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Pravastatin Sodium 40 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
11. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week:
take as before, before breakfast with full glass of water.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): your IRN needs to be closely monitored and dose
adjusted. .
Disp:*10 Tablet(s)* Refills:*0*
14. Albuterol Sulfate 0.083 % Solution Sig: Two (2) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
15. Os-Cal 500 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Flovent 44 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
17. Flonase 50 mcg/Actuation Aerosol, Spray Sig: One (1) Nasal
once a day.
18. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO as
directed: please take 2 pills twice a day for 5 days then take
one pill once a day and follow up with Dr. [**Last Name (STitle) 4541**].
Disp:*30 Tablet(s)* Refills:*1*
19. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 unit* Refills:*0*
20. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
21. Outpatient [**Name (NI) **] Work
PT-INR and Chem 7.
Please call results to Dr. [**Last Name (STitle) 4541**] or Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 62024**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnoses:
1. Abdominal pain, self-resolved
2. Atrial fibrillation with rapid ventricular response
3. Urinary tract infection
4. Hypertension
Secondary diagnoses:
1. Abdominal aortic aneurysm
2. Anemia
3. Gastritis
4. Diverticulosis, sigmoid
5. Duodenal diverticuli
Discharge Condition:
Asymtpomatic. Vital signs stable.
Discharge Instructions:
Please take all medications as prescribed.
Please keep all follow up appointments. You will need to have
you INR monitored closely and coumadin dose adjusted as needed.
Dr. [**Last Name (STitle) 4541**], your new cardiologist, will follow your INR.
Please follow up with Dr. [**First Name (STitle) 437**] about your GI biopsy results.
Please return to care if you have chest pain, fever, abdominal
pain, if you have bleeding that does not stop.
Followup Instructions:
Cardiology: Dr. [**Last Name (STitle) 4541**] ([**Telephone/Fax (1) 62025**] on [**2140-4-25**] at 1:45
pm. You will need to be set up for cardiac monitor (continuous
loop recorder) and your medications will likely need to be
adjusted.
You need to return for capsule endoscopy on [**Last Name (LF) 2974**], [**4-29**]. You
need to have bowel prep prior to the procedure. Please follow
the instructions that were provided to you. Please come to the
[**Hospital Ward Name **], [**Hospital Ward Name 1950**] building, [**Location (un) 453**], at 7:45 am. ([**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1982**], 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:[**2140-4-29**]
8:00)
Primary care: Please call Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 62025**] to arrange
for a follow up appointment within 2 weeks of discharge from the
hospital.
GI: Dr. [**First Name (STitle) 437**], [**2140-5-17**], at 1:20 pm.
Completed by:[**2140-4-24**] Name: [**Known lastname 11182**],[**Known firstname 3551**] Unit No: [**Numeric Identifier 11183**]
Admission Date: [**2140-4-13**] Discharge Date: [**2140-4-22**]
Date of Birth: [**2062-11-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1513**]
Addendum:
13. Liver lesion. Abdominal CT revealed a small, 7mm,
hypervascular lesion within the liver. Differential diagnoses
based on radiographic appearance included hemangioma, nodular
hyperplasia or adenoma. The patient will need outpatient follow
up.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1514**] MD [**MD Number(2) 1515**]
Completed by:[**2140-4-24**]
|
[
"562.10",
"535.10",
"428.0",
"562.00",
"786.59",
"441.02",
"427.31",
"401.9",
"789.06",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
17601, 17815
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5775, 11300
|
288, 348
|
15325, 15360
|
2075, 5752
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1441, 1459
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15027, 15178
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11326, 11331
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15384, 15833
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1474, 2056
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15199, 15304
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234, 250
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376, 797
|
11345, 11742
|
819, 1260
|
1276, 1425
|
11760, 12061
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,351
| 116,062
|
37529
|
Discharge summary
|
report
|
Admission Date: [**2194-10-14**] Discharge Date: [**2194-10-21**]
Date of Birth: [**2123-6-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
bleeding per rectum
Major Surgical or Invasive Procedure:
endoscopy with epinephrine injection
History of Present Illness:
Mr. [**Known lastname 84279**] is a 71 year-old Russian with a history of
coronary artery disease s/p CABG and PCI [**7-/2194**] with DES, as
well as a remote history of gastric ulcers s/p resection of [**1-8**]
of his stomach, who presents with weakness, chest pain, and
bright red blood per rectum. He states that all of these
symptoms have evolved over the past 4 days. The chest pain comes
and goes and is described as pressure similar to his usual
angina. This time it has not been related to exertion but was
responsive to nitroglycerin until an episode last night that was
not. With regard to the BRBPR, he states that this has been
ongoing with most stools for the past 3-4 days and consists of
red blood mixed with brown stool. He denies black stool
(although his daughter states that he has been telling her he is
having black stool). He also denies abdominal pain, nausea,
vomitting, or diarrhea. He denies any history of similar
symptoms. Of note, he did have stomach ulcers in [**Country 532**] in [**2186**]
and is s/p removal of "[**2-6**] of his stomach." He has never had a
colonoscopy.
.
In the ED, initial VS T 98.6, HR 116, BP 110/90, RR 18, O2 100%
RA. Exam was notable for palor and melena in the rectal vault.
EKG was concerning for acute ischemia, and code STEMI was
called. The patient was taken directly to the cath lab without
any heparin given concern for GIB. Catheterization revealed no
change in prior diffuse coronary disease with open stents. A
nitroglycerin drip was started (reportedly for hypertension to
the 170s, although apparently patient was also having ongoing
chest pain).
.
On arrival to the ICU, Mr. [**Known lastname 84279**] complains of ongoing
substernal chest pressure. He denies shortness of breath or
palpitations. He denies abdominal pain, nausea, or vomitting. He
has not had any bowel movement since arrival to the hospital.
Past Medical History:
-hypertension
-dyslipidemia
-CABG: 3 vessels in [**Country 532**]; [**2186**] per patient
-PCI [**11/2193**] with diffuse native disease and grafts open. PTCA
and stenting of proximal LCx with BMS. [**7-/2194**] stenting of Lcx
with DES.
-stomach ulcer s/p resection of [**1-8**] of stomach
-appendectomy
Social History:
He previously smoked 1 PPD but quit in 12/[**2192**]. He has recently
decreased his alcohol intake from TID vodka but unclear exactly
how much he drinks. He lives with his wife.
Family History:
not obtained
Physical Exam:
VS: Afebrile BP 125/65, HR 107, RR 13, O2 100% on RA
GENERAL: appears comfortable, pale, lying flat on back after
cath
HEENT: pale mucosa, oropharynx clear
NECK: supple, JVP not elevated
CARDIAC: regular, no murmur appreciated, no chest wall
tenderness
LUNGS: clear anteriorly
ABDOMEN: Soft, NTND, +BS. No HSM or tenderness.
EXTREMITIES: R groin site clean, dry, nontender. No peripheral
edema. Peripheral pulses not palpable but dopplerable. Evidence
of multiple vein graft harvesting sites.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2194-10-14**] 04:30PM WBC-8.5 RBC-2.65*# HGB-7.0*# HCT-22.1*#
MCV-83 MCH-26.6* MCHC-31.9 RDW-16.5*
[**2194-10-14**] 04:30PM NEUTS-68.5 LYMPHS-25.6 MONOS-4.0 EOS-0.6
BASOS-1.3
[**2194-10-14**] 04:30PM GLUCOSE-124* UREA N-36* CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
Brief Hospital Course:
A 71 year-old man with a history of CAD s/p recent DES on ASA
and Plavix presented with GI bleed.
.
# GI bleed:
In the MICU:
Initially unclear if upper or lower, as patient had variably
endorsed both black stool and brown stool admixed with BRB. Hct
had fallen 38-->30 over 6 months [**11-13**] to [**4-14**]. Had fell an
additional 10 points over the ensuing 6 months, and he did not
follow up with the colonoscopy as an outpatient as instructed on
previous admission. He was given a total of 9 units of pRBC,
and Hct slowly increased although not to the extent expected.
PPI drip was started. Endsoscopy was performed which showed a
bleeding ulcer at the site of his prior anastomosis which was
injected with epinephrine and cauterized. Despite achieving
hemostasis, the patient continued to have melena and a falling
hematocrit requiring transfusion. A second EGD was performed
and the ulcer was cauterized once more for oozing, but it was
the general sense that this oozing was not the source of the
continued bleeding. It was recommended that the patient
follow-up as an outpatient for repeat EGD in [**5-13**] weeks and that
he may need to have a colonoscopy if his hematocrit remains
unstable. He required a totoal of 12 units of blood thoughout
his stay. His aspirin and Plavix were held during his time in
the MICU but aspirin was restarted prior to transfer to the
floor.
On the floor:
PPI was switched to IV BID, two large bore IVs and a type and
cross were maintained. He had a transfusion goal of >30 but did
not require further blood products. His aspirin was restarted on
arrival to the floor. After some debate, his plavix was
restarted one day later because, based on cardiology and GI
consult input, the risk posed for coronary stent occlusion was
deemed superior to GI bleeding. He was rescheduled for an EGD in
6 weeks for a biopsy at the ulcer site. He did not have any more
episodes of melena or hematochezia prior to discharge.
.
.
# CAD:
In the MICU:
Nothing acutely occluding arteries on cath, but the patient had
ongoing severe chest pain with ST depressions precordially
despite a nitroglycerin drip. Thus, he was aggressively
transfused to Hct >30. With this, the nitroglycerin drip was
titrated off, and his home dose of long-acting nitrate was
restarted. Beta blocker was initially held but restarted for
tachycardia likely related to withdrawal of the med and ACEI
were held while there was concern of imminent hemodynamic
instability Aspirin and Plavix were initially held and aspirin
was restarted prior to transfer.
On the floor, Plavix was restarted given the high risk of
coronary stent occlusion knowing that this would pose a greater
risk for repeat GI bleed. His metoprolol and ACE-inhibitor and
statin were also restarted.
.
# Elevated INR: thought to be [**1-7**] nutritional issues. He was
given vitamin K in the MICU.
.
# HTN: chronic issue, patient was normotensive-hypertensive in
the MICU in the setting of bleed. His BP increased once bleeding
stopped and amlodipine and lisinopril were restarted.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. 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.
Disp:*30 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection DAILY (Daily) for 2 days.
Disp:*2 ml* Refills:*0*
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Upper GI bleed
Secondary: CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 84279**],
you were admitted to the [**Hospital3 **] Medical center for a bleed
in your stomach. You were sent to the ICU and seen by the
gastroenterologist you performed 2 esophagealgastroduodenal
(EGD) endoscopies to diagnose and stop the bleeding. Your
ongoing bleeding required 12 Unites of blood before stabilizing.
During your bleeding, your aspirin and plavix were held, but
these were restarted once your bleeding stopped. You were stable
on the floor and did not have repeat episodes of bleeding. Your
hematocrit (a measure of red blood cells) was stable without
transfusions for several days and you were deemed stable for
discharge home.
During your stay some of your medications were changed, you
should START the following:
-Pantoprazole 40mg Twice every day (for decreasing stomach acid)
-Senna and docusate (for constipation)
You should INCREASE:
- Metoprolol to 25 mg twice every day
Please obtain a hematocrit blood test with Dr. [**Last Name (STitle) 3357**] on your
next appointment. You will need a repeat endoscopy at some
point to reevaluate your ulcer and get a biopsy. You will have
to discuss with your cardiologist if it is safe to be off plavix
for this biopsy.
You should continue all your other medications as prescribed by
your physicians. It is important that your take your aspirin and
plavix every day.
Please call your PCP [**Name Initial (PRE) **]/or return to the Emergency if you have
bloody/dark black stools or if your feel lightheaded or dizzy or
have chest pain.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
When: Tuesday, [**10-28**], 9:30AM
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2194-12-9**] at 2:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"V45.81",
"V45.86",
"535.50",
"401.9",
"414.00",
"272.4",
"280.0",
"532.40",
"410.71",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"44.43",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8019, 8025
|
3744, 6809
|
325, 363
|
8108, 8108
|
3413, 3721
|
9816, 10468
|
2813, 2827
|
6832, 7996
|
8046, 8087
|
8258, 9793
|
2842, 3394
|
266, 287
|
391, 2273
|
8123, 8234
|
2295, 2602
|
2618, 2797
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,022
| 169,397
|
37650+58162
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-12-12**] Discharge Date: [**2155-1-8**]
Date of Birth: [**2104-10-21**] Sex: F
Service: SURGERY
Allergies:
Gemfibrozil / Zyrtec / Claritin / Antihistamine Classifier /
Iodine Containing Agents Classifier / Citalopram / Augmentin /
Benadryl / Aspirin
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
[**2154-12-13**]: paracentesis
[**2154-12-24**]: paracentesis
[**2154-12-24**]: EGD/[**Last Name (un) **]; bleeding varix
[**2154-12-24**]: intubation
[**2154-12-24**]: TIPS placed
[**2154-12-30**]: Post-Pyloric feeding tube placement
History of Present Illness:
50F with history of Hep C cirrhosis/HIV recently underwent a
laparoscopic cholecystectomy [**2154-12-4**] for biliary colic/chronic
cholecystitis was seen in clinic today [**12-12**]. She complained of
dizziness, nausea, easily fatigued. A hematocrit was checked in
the office and was 17.9. She was referred to the emergency room
for further workup. She has not had any hematemesis, chills,
fevers, chest pain, shortness of breath, abdominal pain, or
diarrhea.
Past Medical History:
HCV cirrhosis
HIV
cholelithiasis
h/o lower GI bleeding from varices [**12-4**]
ascites
Tubal ligation
appendectomy
Social History:
Immigrated from Poland at age 21. She is a kindergarten teacher.
Divorced with 3 children. Denies etoh, tobacco or other drug use
Family History:
h/o colon ca in maternal grandmother. 3 sons are healthy
Physical Exam:
Temp:97.6 HR:74 BP:100/51 Resp:18 O(2)Sat:100 normal
Constitutional: Comfortable
Chest/Resp: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
GI / Abdominal: Soft, Nontender, mild distention. There is
some mild incisional tenderness.
Rectal: Heme Negative
GU/Flank: No costovertebral angle tenderness
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
On Admission: [**2154-12-12**]
WBC-6.4 RBC-2.10*# Hgb-5.6*# Hct-17.9*# MCV-85 MCH-26.6*
MCHC-31.2 RDW-18.9* Plt Ct-258#
PT-13.2 INR(PT)-1.1
UreaN-11 Creat-0.8 Na-122* K-4.1 Cl-94* HCO3-18* AnGap-14
Glucose-161*
ALT-43* AST-50* AlkPhos-126* TotBili-0.5 Lipase-173*
Albumin-2.9* Calcium-8.0* Phos-1.7*# Mg-1.9
Brief Hospital Course:
50 y/o female who 8 days PTA had a lap chole that was without
complication. She was seen for routine follow up in clinic and
found to be fatigued and dizzy, and on presentation to the ER
her Hct was 17.9 and she was transfused with 2 units RBCs. Her
Hct improved appropriately and she was admitted for abdominal
exams and paracentesis due to ascited seen on CT of abdomen.
Approximately 2 liters of ascites was removed and was reported
as no growth and only 80 WBCs.
She was placed on a fluid restriction and lasix was restarted,
aldactone was still on hold.
ID was consulted who felt that her HIV med regimen was outdated
and should be changed to reflect newer medication choices.
She received another units RBCs on [**12-17**] for Hct 24.8 again
with appropriate increase.
On [**12-17**] the patient was transferred to the SICU due to
hyponatremia despite fluid restriction and attempts to manage
sodium inadequete.
Once her sodium was back to 126 she transferred back to [**Hospital Ward Name 121**] 10
and although chronically ill appearing and having poor appetite
was started to be evaluated for discharge.
She then developed hematemesis and was transferred to the SICU
for an EGD. During the process of the EGD the patient started to
have bright red blood and was determined to have a bleeding
esophageal varix. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] was placed and the the patient was
intubated.
On the same day ([**2154-12-24**]) the patient underwent placement of a
TIPS in IR. Following this procedure the bleeding appreared much
better controlled and the [**Last Name (un) **] was able to be removed once
stable.
The patient received 6 units of RBC's on [**12-24**] units RBCs on
[**12-25**] and 1 unit RBCs on [**12-26**]. Her hematocrit has remained
stable since that time.
During the time of the ICU stay she underwent continued
evaluation for liver transplant. Serologies were sent and scans
were ordered as appropriate.
The patient was transferred out of the ICU on [**12-30**].
A post pyloric feeding tube has been placed and the patient was
started on tube feeds which are now at goal and now being
cycled.
She had some diarrhea noted and c diffs were sent which are
negative. She continues lactulose and should be titrated to 3
BMs daily.
Medications on Admission:
Didanosine 125', Famotidine 20', Lactulose 30ml PO BID,
Nelfinavir 1250 [**Hospital1 **], Spironolactone 100', Tenofovir 300',
Propranolol 20BID, dilaudid 2-4 mg q4prn, Meclizine 12.5', Iron
18 TID, Colace 100"
Discharge Medications:
1. Propranolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every 4
hours) as needed for pain.
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 BMs daily.
9. Lopinavir-Ritonavir 400-100 mg/5 mL Solution Sig: Five (5) ML
PO BID (2 times a day).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Banana Flakes Packet Sig: One (1) packet PO PO tid ().
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
anemic
hyponatremia
UGI bleed/bleeding varices
malnutrition, severe
ileus
HIV
HCV cirrhosis
s/p lap ccy [**2154-12-4**] (previous admission)
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Ambulatory with assist
Discharge Instructions:
Please call if any of the warning signs listed below occur.
Please weigh daily and call Dr [**Last Name (STitle) 17116**] office at [**Telephone/Fax (1) 673**]
if weight increases/decreases > 3 pounds daily or > 5 pounds
from admission weight.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2155-1-21**] 10:00
[**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **] MD Phone [**Telephone/Fax (1) 673**] Date/Time: [**2155-1-23**]: ***CALL
FOR TIME please***
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2155-1-30**] 4:40
Completed by:[**2155-1-8**] Name: [**Known lastname **],[**Known firstname 13409**] B Unit No: [**Numeric Identifier 13410**]
Admission Date: [**2154-12-12**] Discharge Date: [**2155-1-8**]
Date of Birth: [**2104-10-21**] Sex: F
Service: SURGERY
Allergies:
Gemfibrozil / Zyrtec / Claritin / Antihistamine Classifier /
Iodine Containing Agents Classifier / Citalopram / Augmentin /
Benadryl / Aspirin
Attending:[**First Name3 (LF) 3999**]
Addendum:
Please note medications additions and changes that were
recommended per our Infectious Disease service after [**Known firstname **] [**Known lastname **]
was discharged today:
***Change to Lopinavir-Ritonavir 1 TABLET PO BID (instead of
liquid that may have cross reactivity with Flagyl)
Add for H pylori prophylaxis x 14 days:
** Azithromycin 500 mg PO Q24H
** MetRONIDAZOLE (FLagyl) 500 mg PO BID
** Omeprazole 20 mg PO BID
.
Discontinue Ranitidine. [**Month (only) 412**] continue the Omeprazole following
the 14 day H pylori course for continued GI prophylaxis.
.
Please send weekly labs to Fax # [**Telephone/Fax (1) 2858**] (Attn [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
RN)
CBC, Chem 7, Ca, Mg, Phos, LFTs, PT/INR
.
Appointment Time for Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is:
[**2155-1-23**] at 2:00 PM at the [**Hospital **] Medical Building, [**Last Name (NamePattern1) **], [**Location (un) 42**]
.
PICC may be discontinued.
.
Faxed to Radius [**Hospital1 3983**] [**Last Name (un) 13411**], [**Hospital1 3983**], MA 3PM [**2155-1-8**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4185**] [**Hospital **] Hospital
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4000**] MD [**MD Number(2) 4001**]
Completed by:[**2155-1-8**]
|
[
"518.0",
"273.8",
"300.4",
"285.1",
"578.0",
"571.5",
"280.0",
"211.2",
"260",
"572.3",
"V08",
"276.2",
"456.0",
"348.30",
"537.89",
"789.59",
"041.86",
"070.54",
"253.6",
"560.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.04",
"96.06",
"38.91",
"39.1",
"45.13",
"99.15",
"96.6",
"96.71",
"38.93",
"88.64"
] |
icd9pcs
|
[
[
[]
]
] |
8630, 8857
|
2362, 4653
|
413, 650
|
6183, 6183
|
2030, 2030
|
6579, 8607
|
1446, 1504
|
4915, 5901
|
6019, 6162
|
4679, 4892
|
6310, 6556
|
1519, 2011
|
364, 375
|
678, 1144
|
2044, 2339
|
6197, 6286
|
1166, 1282
|
1298, 1430
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,889
| 188,910
|
38669
|
Discharge summary
|
report
|
Admission Date: [**2108-2-22**] Discharge Date: [**2108-2-24**]
Date of Birth: [**2057-4-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Flagyl
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
neck pain and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50yo F PMhx Pancreatic cancer (diagnosed [**3-/2106**], metastatic to
liver with peritoneal implants c/b cirrhosis, portal vein
thromboses, ascites, biliary and small bowel obstruction s/p
bilary and duodenal stenting, c/b nonocclsive thrombus R
subclavian vein [**2-2**] port s/p lovenox initiation ([**10/2108**]) c/b GI
bleeds previously conservatively managed, s/p XRT and C6
gemcitabine, C1 FOLFOX, who presented to [**Hospital1 18**] [**2-22**] with neck
pain and fever to 101. On admission, patient reported
incomplete compliance with home lovenox dosing, was found to
have new occlusive thrombus of the right IJ. Patient was
started on IV heparin for anticoagulation as well as vanco/zosyn
for coverage of infection of uncertain source. Of note,
admission vitals significant for SBP 88 (baseline SBP 90s).
Infection w/u included unremarkable UA, ascites tap w 225 WBCs
(30 polys), unremarkable chest xray. Overnight patient had
episode of BRBPR while passing stool, reported as "enough blood
to fill the toilet", had a repeat Hct that showed Hct 21.2 down
from 27.0. At that time, blood cultures returned positive for
GNRs, and patient's SBP trended down to 80. Clindamycin was
added, heparin was held, and ICU team was called to evaluate.
.
On evaluation on the floor, vital signs were 99.0 80/50 90 16
100%RA. Patient was mildly lethargic, but alert and oriented
x3, comfortable and without complaint.
Past Medical History:
ONC History:
- [**3-/2106**] - Early satiety, RUQ abdominal discomfort, jaundice;
ERCP w biliary duct stent for stricture, brushings
indeterminate. CT angiogram w 2x2.9cm mass in the pancreatic
head with >50% of the SMV encased and soft tissue surrounding
the celiac axis. Not operative candidate.
- [**4-/2106**] - FNA w adenocarcinoma, began gemcitabine
- [**8-/2106**] - cyberknife x3 fractions (3000 cGy), completed 6
cycles gemcitabine, required dose reduction to 800mg/m2 for
counts
- [**5-/2106**] - enrolled in the clinical trial 08-378, u/s negative
for DVT, and she was randomized to enoxaparin 40 mg daily. She
completed this trial without [**First Name8 (NamePattern2) 691**] [**Last Name (un) **].
- ERCP procedures: [**2106-3-29**], [**2106-7-26**], [**2106-11-15**], [**2107-2-14**], [**2107-4-27**]
with stenting of CBD
- [**2107-10-12**] enoxaparin for Nonocclusive thrombus right subclavian
and innominate veins [**2-2**] port
- [**2107-12-8**] C1D1 FOLFOX eventually DC'd for progression
- [**2108-1-13**] New hepatic metastasis. portal vein thrombosis with
splenomegaly and ascites. Peritoneal implants. portosystemic
collaterals, particularly involving the lower esophagus.
.
Other Past Medical History:
Lyme Disease - [**2105-6-1**]
Ascending Cholangitis - [**2107-5-1**]
Social History:
Married with 3 children ages 21, 24, and 26. She is a yoga
teacher. She does not smoke, does not drink alcohol.
Family History:
Grand aunt was diagnosed with breast cancer. Parents are alive
and healthy
Physical Exam:
Vitals: T:97.9 BP:110/70 P:80 O2: 100%
General: alert and oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple but tender over right side, no clear clot felt, JVP
not elevated, LAD on right side.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur, no rubs, gallops
Abdomen: distended, umbilicus distended, bowel sounds present,
no frank fluid wave, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Lab Results:
[**2108-2-22**] 08:24AM BLOOD WBC-13.6*# RBC-3.82* Hgb-8.9* Hct-27.9*
MCV-73* MCH-23.2* MCHC-31.8 RDW-19.9* Plt Ct-403
[**2108-2-22**] 08:24AM BLOOD Neuts-98.1* Lymphs-1.1* Monos-0.4*
Eos-0.2 Baso-0.2
[**2108-2-22**] 11:29PM BLOOD WBC-16.7* RBC-2.95* Hgb-6.8* Hct-21.2*
MCV-72* MCH-23.1* MCHC-32.2 RDW-20.4* Plt Ct-214
[**2108-2-22**] 08:24AM BLOOD PT-12.9* PTT-32.1 INR(PT)-1.2*
[**2108-2-22**] 11:29PM BLOOD PT-15.5* PTT-37.5* INR(PT)-1.5*
[**2108-2-22**] 08:24AM BLOOD Fact X-77
[**2108-2-22**] 08:24AM BLOOD Glucose-87 UreaN-12 Creat-0.4 Na-125*
K-4.1 Cl-94* HCO3-21* AnGap-14
[**2108-2-22**] 11:29PM BLOOD Glucose-130* UreaN-11 Creat-0.4 Na-126*
K-3.5 Cl-98 HCO3-20* AnGap-12
[**2108-2-22**] 08:24AM BLOOD ALT-73* AST-71* AlkPhos-683* TotBili-0.8
[**2108-2-22**] 11:29PM BLOOD ALT-54* AST-60* LD(LDH)-302* CK(CPK)-136
AlkPhos-422* TotBili-1.0
[**2108-2-22**] 08:24AM BLOOD Lipase-11
[**2108-2-22**] 11:29PM BLOOD CK-MB-3 cTropnT-<0.01
[**2108-2-22**] 11:29PM BLOOD Calcium-7.2* Phos-2.0* Mg-1.6
[**2108-2-22**] 08:24AM BLOOD Albumin-2.4*
[**2108-2-22**] 08:37AM BLOOD Lactate-1.6
[**2108-2-22**] 11:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2108-2-22**] 11:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
[**2108-2-22**] 10:34AM ASCITES WBC-225* RBC-325* Polys-30* Lymphs-31*
Monos-21* Mesothe-1* Macroph-17*
[**2108-2-22**] 10:34AM ASCITES TotPro-0.5 Glucose-100
[**2108-2-22**] 8:24 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2108-2-23**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2108-2-23**] AT
0005.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2108-2-23**]): GRAM
NEGATIVE ROD(S).
[**2108-2-22**] 10:34 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2108-2-23**]): GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2108-2-23**]): GRAM NEGATIVE
ROD(S).
[**2108-2-22**] 10:34 am PERITONEAL FLUID
GRAM STAIN (Final [**2108-2-22**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
[**2108-2-22**] 11:25 am URINE
URINE CULTURE (Pending):
CHEST (PA & LAT) Study Date of [**2108-2-22**] 8:45 AM
FINDINGS: Again noted is a Port-A-Cath in the chest wall of the
upper right hemithorax with the tip of the catheter ending in
expected position at the cavoatrial junction. The lungs are well
expanded and clear, with the exception of a small discoid
atelectasis noted in the left lung base.
Cardiomediastinal and hilar contours are unremarkable. There is
no evidence of pleural effusion or pneumothorax.
IMPRESSION: No evidence of acute cardiopulmonary process
UNILAT UP EXT VEINS US RIGHT Study Date of [**2108-2-22**] 9:22 AM
FINDINGS: Duplex was performed of the right upper extremity
veins. Limited
views of the left subclavian vein were obtained for comparison.
There is
normal phasic flow in the left subclavian vein. Views of the
right subclavian vein were limited by the port. There is a
partially occlusive thrombus in the right subclavian vein. The
proximal extent of the thrombus is not seen. An occlusive
thrombus of the right internal jugular vein is present. The
right axillary, brachial, cephalic, and basilic veins
demonstrate normal compression and augmentation.
IMPRESSION:
1. Occlusive thrombus of the right IJ.
2. Non-occlusive thrombus of the right subclavian vein. Proximal
extent not seen.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2108-2-22**]
10:28 AM
ReportIMPRESSION:
Preliminary Report1. Sludge within the gallbladder.
Preliminary Report2. Moderate to large ascites, unchanged from
prior abdominal CT allowing for
Preliminary Reportdifference in techniques.
Preliminary Report3. No focal liver lesion identified. Echogenic
liver consistent with fatty
Preliminary Reportinfiltration.
CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of [**2108-2-22**] 6:09 PM
R IJV thrombus extending from level of port to upper neck, not
into sigmoid sinus. 1-cm L thyroid nodule for nonemergent US.
Brief Hospital Course:
50yo F PMhx metastatic pancreatic cancer with multiple
complications including ascites and nonocclsive thrombus R
subclavian vein presenting with fever, found to have bacteremia
and new occlusive thrombus of the right IJ, as well as thrombus
in the right atria possibly attached to portacath tip.
# Pancreatic Cancer:
Nonoperative pancreatic cancer with metastases to liver. Pt has
undergone several treatment therapies including cyberknife and
chemo. Also had several ERCPs w/ CBD stents placed.
Hypercoaguable with several clots extending through the RIJ and
subclavian, potentially into right atrium. Given the numerous
complications associated with her cancer, the patient decided
that she would prefer to go home with hospice.
# Clot
Large area of right IJ and subclavian were found to be full of
clot, likely surrounding portacath as well. Small mobile
thrombus was also seen in the right atrium. Anticoag had to be
stopped for a GI bleed. There was concern that the portacath was
infected, but given the clot burden, the patient elected not to
remove it.
# GI Bleed
Most likely etiology is hemobilia from multiple stents leading
to BRBPR and melena.
Patient refused further EGD or ERCP for further evaluation.
Required stopping of anticoagulation, which was a particularly
concerning given her large clot burden.
# Sepsis
Found to be hypotension on admission, which was most likely due
to a combination of GNR found in the blood as well as the GI
bleed. Started on broad spectrum antibiotics for coverage,
eventually narrowed to PO cipro on discharge given the pan
sensitivity of the GNR.
# Ascites: due to portal vein thrombosis. w/ pleurex pt is able
to draw off 2L fluid every other day. peritoneal fluid
inconsistent w/ SBP.
Medications on Admission:
HOME MEDICATIONS:
- Oxycodone 5mg Q4H prn
- Lorazepam 0.5mg q6H prn anxiety, nausea
- Creon 3 tablets TID w meals
- Omeprazole 20mg [**Hospital1 **]
- Lovenox 60mg SQ [**Hospital1 **]
.
MEDICATIONS ON TRANSFER
- Omeprazole 20mg [**Hospital1 **]
- Pancrelipase 5000 3 CAP PO TID W/MEALS
- Piperacillin-Tazobactam 4.5g IV Q8H
- Clindamycin 600mg IV Q6H
- Vancomycin 1000mg IV Q12H
Discharge Medications:
1. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
4. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous twice a day.
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Location (un) 86**] and Greater [**Hospital1 1474**]
Discharge Diagnosis:
Metastatic pancreatic cancer
Gram negative rod bacteremia
Venous thromboembolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 85910**],
You were admitted to the hospital with low blood pressure and a
large clot that are both related to your worsening pancreatic
cancer. You were found to have an infection and will be treated
with antibiotic. You will also go home with hospice which will
help you with your medical needs.
Followup Instructions:
Please contact your primary care physician and oncologist for
follow-up as you feel is appropriate.
|
[
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"038.9",
"157.9",
"197.6",
"V12.51",
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icd9cm
|
[
[
[]
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[] |
icd9pcs
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[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,965
| 100,431
|
51930
|
Discharge summary
|
report
|
Admission Date: [**2149-10-9**] Discharge Date: [**2149-10-17**]
Date of Birth: [**2073-7-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 21990**]
Chief Complaint:
bright red blood in stool
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
76F with no prior history of GI bleed, HTN, Sciatica who was at
rehab for back pain, who for the past 2 weeks has had
constipation & crampy abdominal pain associated with increased
belching, flatus. Patient is written for narcotics for pain
control of sciatica but is unaware of whether she's taken them.
On the morning of admmission she had 4 episodes of blood per
rectum with initial bowel movements, which relieved her
abdominal discomfort, and were described as dark maroon blood
mixed with stool progressing to BRBPR. Patient denies any
associated lightheadedness, dizziness, CP, SOB, change in
vision, hematuria, epistaxis, ASA, NSAID, or EtOH use. Patient
has never had a colonoscopy and there is no family history of
colon cancer. Patient denies weight change or change in
appetite. She says she and staff at rehab have disagreed about
bowel regimen, and she may not have been receiving one
regularly.
Past Medical History:
HTN
Sciatica, L4/5 lumbar spondylolisthesis--seen by ortho.
Shoulder injury--associated with weakness.
OA--knees, bilat.
Cervical Joint Disease
Depression
Narrow angle glaucoma
Social History:
Patient emigrated from [**Location (un) **] > 50 yrs ago. Used to work as
a translator. Currently lives in senior housing in JP with 12 yr
old granddaughter. Lives in elder housing with her 12 year old
grandaughter. Per OMR, DSS was to get involved given that
granddaughter was not in school: "complicated family dynamics".
Per pastor who is friend of the patient, the child is in school
and issue is resolved for now. She denies any EtoH, tobacco, or
illicit drug use.
Family History:
Patient denies any family history of colon cancer. patient has
one living relative who is [**Age over 90 **] years of age.
Physical Exam:
Vitals - T:98.7 BP:155/66 HR:62 RR:16 02 sat:94 RA
GENERAL: laying in bed, NAD
SKIN: 8cm vertical old, small multiple subcentimeter
hypopigmented macules on lower extremities, well healed incision
scar on mid abdomen, warm and well perfused, no excoriations or
no rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pale conjunctiva,
patent nares, dry mucus membranes, good dentition, supple neck,
no LAD, no JVD
CARDIAC: RRR, S1/S2, soft SEM @ RUSB
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
[**2149-10-9**] 12:15PM PT-12.4 PTT-31.3 INR(PT)-1.1
[**2149-10-9**] 12:15PM PLT COUNT-327
[**2149-10-9**] 12:15PM NEUTS-68.9 LYMPHS-22.7 MONOS-6.3 EOS-2.0
BASOS-0
[**2149-10-9**] 12:15PM WBC-4.2 RBC-3.39* HGB-10.9* HCT-31.3* MCV-92
MCH-32.1* MCHC-34.8 RDW-13.2
[**2149-10-9**] 12:15PM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.2
[**2149-10-9**] 12:15PM GLUCOSE-105 UREA N-10 CREAT-0.9 [**Month/Day/Year 11516**]-123*
POTASSIUM-4.7 CHLORIDE-87* TOTAL CO2-26 ANION GAP-15
[**2149-10-9**] 12:39PM HGB-11.0* calcHCT-33
[**2149-10-9**] 03:45PM PLT COUNT-287
[**2149-10-9**] 03:45PM NEUTS-69.9 LYMPHS-23.7 MONOS-4.2 EOS-2.1
BASOS-0.1
[**2149-10-9**] 03:45PM WBC-4.4 RBC-3.58* HGB-11.6* HCT-33.5* MCV-94
MCH-32.4* MCHC-34.6 RDW-13.4
[**2149-10-9**] 07:06PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2149-10-9**] 07:06PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2149-10-9**] 07:06PM URINE OSMOLAL-113
[**2149-10-9**] 09:36PM HCT-28.3*
.
[**2149-10-10**] 04:57AM BLOOD WBC-8.7# RBC-3.77* Hgb-11.9* Hct-34.9*
MCV-93 MCH-31.5 MCHC-34.1 RDW-13.5 Plt Ct-288
[**2149-10-10**] 07:04PM BLOOD Hct-34.5*
[**2149-10-11**] 05:55AM BLOOD WBC-8.0 RBC-3.50* Hgb-11.0* Hct-33.0*
MCV-94 MCH-31.5 MCHC-33.4 RDW-13.9 Plt Ct-273
[**2149-10-11**] 05:55AM BLOOD Glucose-71 UreaN-5* Creat-0.6 Na-139
K-3.6 Cl-102 HCO3-25 AnGap-16
[**2149-10-17**] 05:40AM WBC 5.4 Hgb 10.3* HCT 30.9* MCV 95 Plt 256
[**2149-10-17**] 09:55AM HCT 33.3*
.
[**10-10**] Colonoscopy: Findings:
Excavated Lesions Multiple diverticula with medium openings
were seen in the whole colon.Diverticulosis appeared to be
severe. A single diverticulum with signs of inflammation was
seen in the ascending colon.Diverticulosis appeared to be of
mild severity.
Impression: Diverticulosis of the whole colon. Diverticulum in
the ascending colon
.
[**10-15**] Tagged RBC Findings: Negative GI bleeding study.
.
[**10-13**] MRI L-spine: The alignment of the lumbar spine demonstrate
minimal anterolisthesis at L4-L5. The signal intensity in the
vertebral bodies is slightly heterogeneous, likely consistent
with degenerative changes. The intervertebral disc space at
L1-L2 appears unremarkable. At L2-L3 no significant neural
foraminal narrowing or spinal canal stenosis is identified.
L3-L4 demonstrates disc desiccation and mild posterior diffuse
disc bulge producing mild bilateral neural foraminal narrowing,
no frank evidence of nerve root compression is detected.
Bilateral hypertrophy of the articularjoint facets as well as
the ligamentum flavum is observed at this level. At L4-L5, there
is evidence of disc desiccation, mild posterior broad-based disc
bulge producing bilateral neural foraminal narrowing, right
greater than left with possible contact on the right [**Name (NI) 5774**] nerve
root, please correlate specifically with this finding, bilateral
articular joint facet hypertrophy is also noted associated with
bilateral ligamentum flavum thickening. At this level, there is
evidence of significant spinal canal stenosis, the thecal sac
measures approximately 6 mm in the anterior, posterior diameter.
At L5-S1, there is evidence of disc desiccation, posterior
broad-based disc bulge producing bilateral neural foraminal
narrowing and significant spinal canal stenosis, left greater
than right with possible contact on the [**Name (NI) 13032**] nerve root.
Bilateral articular joint facet hypertrophy and ligamentum
flavum thickening is noted at this level. There is also
evidence of irregular contour of the inferior endplate at L5
consistent with a Schmorl's node and bone marrow replacement for
fat in the endplates. Vacuum phenomena is also detected in the
intervertebral disc space. The sacroiliac joints, visualized
aspect of the retroperitoneum and vascular structures appear
grossly normal. IMPRESSION: Multilevel degenerative changes of
the lumbar spine as described in detail above. At L4-L5, there
is evidence of disc desiccation and posterior broad-based disc
bulge producing right side neural foraminal narrowing with
possible contact on the right nerve root of [**Name (NI) 5774**]. At L5-S1, there
is evidence of a left paracentral disc protrusion producing left
side neural foraminal narrowing and possible contact on the left
[**Name (NI) 13032**] nerve root, moderate-to-severe spinal canal stenosis is
identified at this level.
Brief Hospital Course:
76 year old female with history of HTN and sciatica presented
with 4x BRBPR in setting of 2 weeks intermittent constipation.
Brief hospital course by problem:
1.Diverticular bleed - The patient presented with BRBPR x4 and
gassy abdominal pain in the setting of intermittent constipation
of several weeks duration. GI was consulted, a NG lavage in the
ED was negative, and the patient was treated with fluid
resucitation with her systolic pressure running below baseline
in the 110s. Hematocrit on admission was 31.3 and stable for the
first 12 hours. She had no white count, temperature or acute
abdominal pain. She was transferred to the MICU for observation
overnight and prep for a colonoscopy in the am. She had one
episode of hypotension into the 90s associated with
lightheadedness and one bloody BM overnight. Her hct dropped to
28.3 and early on [**10-10**] she was transfused 2 u PRBCs with an
increase back to 34.9. She went for colonoscopy where numerous
diverticula were seen throughout the colon, at least one with
evidence of inflamation. Though no source of acute bleeding was
seen, diverticuli were felt to be the etiology of bleed. She was
transferred to the floor and remained hemodynamically stable. On
[**10-12**] however, she experienced renewed melanotic stools and was
transferred to the MICU for observation. Her hematocrit remained
>30, and she returned to the floor on [**10-13**]. Late on [**10-14**] her
first bowel movement since her MICU stay was streaked with
bright red blood, and she was sent for a tagged red blood cell
scan which did not demonstrate any bleeding. She remained
hemodynamically stable and passed another stool with difficulty
on [**10-16**] that was formed, brown, but streaked with bright red
blood, thought likely secondary to hemorrhoids. Her HCT was
stable and was at baseline (33.3) on the morning of discharge.
She will need to continue on an aggressive bowel regimen to
prevent constipation as this may have aggravated what was surely
underlying but silent diverticular disease.
.
2.HTN: The patient has a history of hypertension on HCTZ and
CCB. These were held on [**10-9**] and [**10-10**] secondary to bleeding, but
were restarted on [**10-11**] as the patient was hemodynamically
stable.
.
3.Sciatica - The patient continued to complain of lower back
pain radiating into her leg consistent with her well documented
hx of sciatica and L4/5 disease. She was seen by orthopaedics,
who had recommended medical treatment and physical therapy with
followup with ortho-spine if symptoms persist. She comes to
[**Hospital1 18**] from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] where she has been receiving
rehabilitation for this condition. She was continued on Tylenol
and opioids for breakthrough pain. It appears her Amitryptiline
had been recently discontinued. Opioids were initially used
cautiously and at low doses given constipation and its role in
potentially instigating her bleed, with minimal requests. Pain
control was adequate at rest, but she was unable to ambulate.
She complained of increased left lower extremity weakness and
was sent for an MRI of her lumbar spine. MRI demonstrated the
following findings: 1. Multilevel degenerative changes of the
lumbar spine; 2. At L4-L5, there is evidence of disc desiccation
and posterior broad-based disc bulge producing right side neural
foraminal narrowing with possible contact on the right nerve
root of [**Name (NI) 5774**]; 3. At L5-S1, there is evidence of a left paracentral
disc protrusion producing left side neural foraminal narrowing
and possible contact on the left [**Name (NI) 13032**] nerve root,
moderate-to-severe spinal canal stenosis is identified at this
level. She was examined by the spine team who felt that she
would likely benefit from an inpatient pain consult and
outpatient work-up of her spine findings. They deferred surgical
intervention at this point given her unresolved GI bleeding
issues. The chronic pain team was consulted and deferred steroid
injection, saying that it might aggrevate her GI bleeding. Under
their recommendation she was started on neurontin 300mg TID to
assist with the pain. She is to follow up with orthopedics and
chronic pain clinics as an outpatient.
.
She is being discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] on standing Tylenol and
neurontin with oxycodone for breakthrough pain. We have
reinforced the importance of continuing a bowel regimen if she
continues narcotic pain medication.
.
4. Hyponatremia: Patient had a serum Na of 123 at presentation.
Per her PCP, [**Name10 (NameIs) **] was 138 on [**9-24**]. Hyponatremia was thought
likely secondary to volume depletion in the context of blood
loss +/- cathartic diarrhea. The urine was paradoxically dilute
with Uosm =113. A serum [**Month/Year (2) **] post-fluid repletion was 140.
.
5. Social: Patient was very distressed on [**10-11**] am regarding a
situation with her non-biological 12 year old granddaughter
[**Name (NI) 17976**], who is in her care. Her estranged biological daughter
[**Name (NI) 107509**] was threatening to call DSS to remove [**Last Name (un) 17976**] from a
friend's apartment where she's staying. DSS was involved in
past, but the patient's pastor confirms that she has helped to
resolve that issue by enrolling [**Last Name (un) 17976**] in school. The daughter
additionally came to the hospital to convey the message that
patient is drug seeking. The patient denied overuse of
medications, and this accusation was not verified by her pastor
or primary care physician.
.
Dispo: The patient was discharged back to her rehabilitation
center in stable condition with instructions to return to the
hospital if she has another bowel movement with significant
blood loss (more than bright red blood streaking) or if she
becomes hemodynamically unstable.
Code: FULL.
Medications on Admission:
Tylenol
Valium 5 mg prn
Oxycodone 5mg prn
Timolol ophth
Verapamil 240 mg qd
HCTZ 25 mg qd
Ibuprofen 600mg QID
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours): Hold for SBP <100;
HR <55.
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP<95.
5. Docusate [**Last Name (un) **] 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 1 weeks: Take for breakthrough
pain. Avoid if possible if constipated.
Disp:*28 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
1)Diverticular bleeding
2)Sciatica from lumbar degenerative disease and disc compression
of nerve roots
Secondary Diagnoses:
1)Hypertension
Discharge Condition:
Hemodynamically stable. HCT 33.3 (baseline). No large bloody
stool since [**10-12**]. Since then she has had 2 formed stools with a
small amount of blood streaking on the outside.
Discharge Instructions:
You have been diagnosed with diverticular bleeding, a condition
in which abnormal outpouchings in the wall of your intestines
can cause rapid bleeding via your rectum. We treated you with
fluids and a blood transfusion for support and completed a
colonoscopy to locate any specific sources of the bleeding. It
was this test that showed the diverticula (outpouchings).
Constipation may cause diverticula or cause them to bleed. It is
very important that you continue on the regimen we've outlined
to keep your bowels moving regularly. Your outpatient doctors
[**Name5 (PTitle) **] [**Name5 (PTitle) 9004**] to adjust your pain medications, since opioid narcotics
(oxycodone, morphine, etc.) can aggravate constipation,
especially if you are not taking other agents to keep your
bowels moving.
We continued to treat your sciatica with pain medication. We
obtained an MRI of the lumbar spine which showed disc protrusion
and possible compression of some of your lumbar nerve roots
which would explain your symptoms. You were evaluated by
orthopedics who deferred surgical intervention at this point
given your other medical issues. By their recommendation you
were evaluated by the chronic pain clinic who decided not to
give you a steroid injection at this point, but recommended
adding neurontin to your medications for pain management. We
started this medication as well. You are being discharged to
[**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] where physical therapists and doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **]
with you more to treat this condition. We are recommending that
you take tylenol four times a day and oxycodone as needed for
breakthrough pain. We have also added a new medication
(protonix) to help prevent your stomach from forming ulcers
which may bleed. Please take this medication as prescribed.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6924**], to schedule a
follow-up visit once you leave rehab. You should also modify
your diet to include adequate fiber as this may help prevent
constipation and diverticular disease.
If you experience any blood in your stools (more than just blood
streaks), black stools, maroon-colored stools, or change in your
bowel movements, you should contact your primary care physician
or go to the emergency room. Please also seek medical attention
if you experience chest pain, shortness of breath, dizziness,
lightheadedness or weakness.
Followup Instructions:
- Please contact Dr. [**Last Name (STitle) 6924**] at [**Hospital3 4262**] Group to schedule a
followup visit once you are discharged from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
Rehabilitation.
- Please keep your previously scheduled appointment for your eye
testing and with your eye doctor, [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. on
[**2149-10-20**] 10:30 and 11:00. If you need to reschedule, please call
his office at [**Telephone/Fax (1) 253**].
- Please also follow-up with your neurologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2149-11-6**] 12:00. If you need to reschedule, please
call her office at [**Telephone/Fax (1) 541**].
- Please also follow-up with your chronic pain clinic
appointment on [**2149-12-3**] at 1:40pm. It is located in
the pain management center which is in the [**Hospital Ward Name 1950**] Building Fth
Floor.
- You also have a follow-up appointment with Dr. [**Last Name (STitle) **] in
orthopedics on [**2149-11-6**] at 1:40 pm.
Completed by:[**2149-10-17**]
|
[
"455.5",
"564.00",
"458.9",
"276.8",
"738.4",
"276.1",
"401.9",
"562.12",
"365.20",
"721.0",
"724.3",
"726.2",
"715.36",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
14495, 14568
|
7315, 7446
|
342, 356
|
14772, 14954
|
2867, 7292
|
17488, 18576
|
1999, 2123
|
13368, 14472
|
14589, 14713
|
13233, 13345
|
14978, 17465
|
2139, 2848
|
14734, 14751
|
277, 304
|
7475, 13207
|
384, 1296
|
1318, 1496
|
1512, 1983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,508
| 103,334
|
1863
|
Discharge summary
|
report
|
Admission Date: [**2176-10-9**] Discharge Date: [**2176-10-16**]
Date of Birth: [**2113-4-24**] Sex: F
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10416**]
Chief Complaint:
post op for close monitoring
Major Surgical or Invasive Procedure:
s/p ventral hernia repair
History of Present Illness:
HPI: pt is a 63 yo lady w/ remote smoking history, obesity, who
is s/p extensive ventral hernia repair this evening w/ mesh
placment, who was transferred from PACU for close monitoring in
setting of mild hypoxia, tachycardia, and ?EKG changes. She had
an uneventful, intraoperative and postoperative course until she
was noted to be mildly hypoxic to 94% on 2L (no room air sat
recorded) in the PACU, tachycardic, with ?new q waves on her
EKG. She was transferred to the [**Hospital Unit Name 153**] for overnight observation.
She receieved approximately 500 cc of IVF intraoperatively. On
arrival to [**Hospital Unit Name 153**], patient had no complaints except for
post-operative, abdominal pain. She denies chest pain or
shortness of breath.
Past Medical History:
1. POD #0 -- Ventral hernia repair, Extensive lysis of
adhesions, Placement of mesh for abdominal wall reconstruction,
Closure of abdominal wall skin defect.
2. Nephrolithiasis [**2166**], multiple stones in the right lower pole
calyx
s/p Cystoscopy, stents, extracoporeal shock wave lithotripsy
3. ccy
4. longtime smoker- quit [**2166**]
5. obesity
6. h/o diverticulosis w/ resection and subsequent colostomy with
reversal
7. h/o ventral hernia repairs in past, last several years ago
8. depression
Social History:
Born in [**Country 2559**], moved here 40+years ago; lives in [**Location 10417**] w/
husband; has involved daughter. Phone numbers in chart. Remote
smoker-quit [**2166**]; denies every drinking alcohol "I don't even
drink the wine my husband makes."
Family History:
not elicited
Physical Exam:
PE: T 99.5 BP 91/50 HR 117 sinus tachy R 20 93% 4L
Gen: obese, Italian woman, pleasant, tired, no distress
HEENT: MM dry, NG tube in place with minimal drainage, NC in
place
CHEST: scant bibasilar crackles
CV: tachy, regular, distant heart sounds, no m/r/g
ABD: obese, binder in place with large abd dressing; 2 JP drains
in place, draining serosanguinous fluid, appropriately tender
abdomen
EXTRM: scant edema, warm and well perfused, strong peripheral
pulses
NEURO: intact, good historian; not fully assessed
Pertinent Results:
[**2176-10-9**] 06:30PM GLUCOSE-161* UREA N-23* CREAT-1.0 SODIUM-141
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
[**2176-10-9**] 06:30PM CK(CPK)-51
[**2176-10-9**] 06:30PM CK-MB-2 cTropnT-<0.01
[**2176-10-9**] 06:30PM ALBUMIN-3.4 CALCIUM-8.6 PHOSPHATE-3.6
MAGNESIUM-1.5*
[**2176-10-9**] 06:30PM WBC-11.1* RBC-3.89* HGB-10.9* HCT-33.1*
MCV-85 MCH-27.9 MCHC-32.8 RDW-14.8
[**2176-10-9**] 06:30PM PLT COUNT-324
[**2176-10-9**] 04:09PM TYPE-ART TEMP-36.8 RATES-/20 O2-50 PO2-103
PCO2-38 PH-7.36 TOTAL CO2-22 BASE XS--3 INTUBATED-INTUBATED
VENT-SPONTANEOU
[**2176-10-9**] 11:19AM TYPE-ART PO2-158* PCO2-32* PH-7.45 TOTAL
CO2-23 BASE XS-0
[**2176-10-9**] 11:19AM GLUCOSE-183* LACTATE-2.3* NA+-136 K+-3.9
CL--114*
[**2176-10-9**] 11:19AM HGB-10.2* calcHCT-31
[**2176-10-9**] 11:19AM freeCa-1.07*
Brief Hospital Course:
63F s/p extensive ventral hernia repair. She tolerated the
sugery well. Post-operatively, she had persistent,mild hypoxia
post extubation. The Medical Service was immediately consulted
for low oxygen saturation. She was placed on supplemental
oxygen post-extubation and was eventually weaned off. On the
day of discharge, her oxygen sat was 96% on room air.
With respect to her wound, in continued to remained
clean/dry/intact. There was some erythema post-operatively,
which is now much improved with antibiotic treatment. She has
been afebrile with stable vitals, eating well, ambulating,
making good urine and stool. She will be discharged, in good
condition, to home with a visiting nurse to be by to evaluate
for possible home physical therapy services.
Medications on Admission:
celexa 10 mg po qd
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed: FOR NAUSEA
.
Disp:*30 Tablet(s)* Refills:*0*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 2 weeks.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
EXTENSIVE VENTRA HERNIA
Discharge Condition:
GOOD
Discharge Instructions:
PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS
CAREFULLY. IF SIGNS AND SYMPTOMS OF INFECTION, SUCH AS
FEVERS/CHILLS, PURULENT DISCHARGE FROM WOUND/INCISION SITE,
INCREASED REDNESS, INCREASED PAIN, PLEASE CALL OR GO TO THE
EMERGENCY ROOM. REMEMBER TO CALL TO SCHEDULE YOUR FOLLOW UP
APPOINTMENT (BELOW). LIGHT ACTIVITIES UNTIL SEEN IN CLINIC.
REMEMBER TO WHERE ABDOMENAL BINDER AS INSTRUCTED.
Followup Instructions:
PLEASE CALL [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10418**], M.D. ([**Telephone/Fax (1) 10419**] TO BEEN SEEN IN
1 WEEK.
Completed by:[**2176-10-16**]
|
[
"V12.79",
"V15.82",
"276.5",
"553.20",
"997.4",
"997.3",
"496",
"568.0",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.69",
"54.59",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
4796, 4854
|
3360, 4131
|
345, 372
|
4922, 4929
|
2516, 3337
|
5386, 5564
|
1955, 1969
|
4200, 4773
|
4875, 4901
|
4157, 4177
|
4953, 5363
|
1984, 2497
|
277, 307
|
400, 1147
|
1169, 1671
|
1687, 1939
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,641
| 137,552
|
26246+57492
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-8-23**] Discharge Date: [**2191-9-6**]
Service: UROLOGY
Allergies:
Opioid Analgesics / Adhesive Tape
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
TCC
Major Surgical or Invasive Procedure:
Right nephroureterectomy
History of Present Illness:
88F with a hx of CIS s/p BCG/interferon/mitomycin but continued
Positive cytologies presented in [**3-22**] with R flank pain and HUN.
CT scan with delayed images and IV contrast identified a
filling defect in the right distal ureter and subsequent
Ureteral brushings of strictured area seen on ureteroscopy were
positive for malignant cells.
GENERAL MEDICAL HISTORY: Bladder CA with recurrent right
ureteral tumor. Esophageal diverticulum. Bilateral shoulder
arthritis.
ALLERGIES: Codeine, Demerol, morphine, Naprosyn, Percocet,
lepirudin, and Vicodin.
Meds: Lescol 80, procardia 30, Klor-con 8 [**Hospital1 **], metoprolol xl 25,
lasix 40, neurontin 600, timolol/xalatan eyedrops. (ASA)
Past Medical History:
Bladder cancer described above
Breast cancer s/p left masectomy
Ischemic cardiomyopathy s/p MI [**2155**] and [**2157**], s/p angioplasty
10yrs ago, EF 35%
H/o VEA VT arrythmia
HTN
Headache
Vertigo
Glaucoma
Blindness
Poor hearing
Social History:
Lives alone
No EtOH
No tob
Brief Hospital Course:
Patient was admitted to Urology after undergoing R radical
nephroureterectomy. No concerning intraoperative events
occurred; please see dictated operative note for details. The
patient received perioperative antibiotic prophylaxis. She
remained in PACU the first night prior to transfer to the [**Hospital Unit Name 153**]
for volume management given her history of CHF. The patient was
transferred to the floor from the [**Hospital Unit Name 153**] in stable condition. She
developed increased ectopy, chest pain, and and oxygen
requirement. Diuresis was initiated and cardiac enzymes
monitored with Cardiology consulting. Pt was medically managed
with enzymes downtrending. Pt had prolonged ileus with
amylase/lipase elevation. GI was consulted and pt maintained NPO
until resolved. PT/OT was consulted and recommended disposition
to Home with PT/OT. The patient was discharged in stable
condition, eating well, ambulating independently, voiding
without difficulty, and with pain control on oral analgesics. On
exam, incision was clean, dry, and intact, with no evidence of
hematoma collection or infection. The patient was given explicit
instructions to follow-up in clinic with Dr. [**Last Name (STitle) 261**] in [**12-15**]
weeks.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Follow up with your cardiologist about this medicine.
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days: Take first dose the day before your appointment with Dr.
[**Last Name (STitle) 261**].
Disp:*10 Tablet(s)* Refills:*0*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Over the counter. Take with food. Follow up with your
cardiologist.
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Transitional Cell Cancer of Right kidney and ureter
Discharge Condition:
Stable
Discharge Instructions:
-You may take motrin and narcotic together for pain control
-You may shower 2 days after surgery, but do not tub bathe,
swim, soak, or scrub incision for 2 weeks.
-Allow bandage strips to fall off over time, remove all
remaining dressings in 2 days
-No heavy lifting for 4 weeks (no more than 10 pounds)
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
-Follow up in 1 week for wound check/foley removal
-Please do not drive or consume alcohol while taking pain
medications.
-Take first dose of Ciprofloxacin 1 day prior to foley catheter
removal and for subsequent 4 days.
- Wear Large foley bag for majority of time, leg bag is only for
short-term when leaving house.
Followup Instructions:
Call for appointment with Dr. [**Last Name (STitle) 261**] at [**Telephone/Fax (1) 277**].
Completed by:[**2191-9-8**] Name: [**Known lastname **],[**Known firstname 11471**] Unit No: [**Numeric Identifier 11472**]
Admission Date: [**2191-8-23**] Discharge Date: [**2191-9-6**]
Date of Birth: [**2102-10-14**] Sex: F
Service: UROLOGY
Allergies:
Opioid Analgesics / Adhesive Tape
Attending:[**First Name3 (LF) 1361**]
Addendum:
The patient had an elevated creatinine post-operatively because
she had a kidney removed. She had an elevated cardiac enzyme
profile but Cardiology felt is was not a new infarct as the
imaging was consistant with the distribution of previous
ischemic events. She was not treated for ARF or CHF specifically
during this hosptalization.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1362**] MD [**MD Number(1) 1363**]
Completed by:[**2191-10-13**]
|
[
"401.9",
"369.4",
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"414.8",
"458.29",
"428.0",
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"276.2",
"997.4",
"413.9",
"V10.3",
"276.7",
"530.6",
"790.5",
"518.7",
"389.9",
"560.1",
"428.22",
"412",
"V10.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
5615, 5826
|
1321, 2560
|
243, 270
|
3923, 3932
|
4770, 5592
|
2583, 3753
|
3848, 3902
|
3956, 4747
|
200, 205
|
298, 999
|
1021, 1253
|
1269, 1298
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,443
| 195,487
|
35548
|
Discharge summary
|
report
|
Admission Date: [**2124-3-6**] Discharge Date: [**2124-4-4**]
Date of Birth: [**2066-11-6**] Sex: M
Service: MEDICINE
Allergies:
Precedex
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Found unresponsive.
Major Surgical or Invasive Procedure:
-Endotracheal intubation
-PICC line
-Arterial line
History of Present Illness:
This is a 57 year old homeless male with PMH of CHF, A. fib, DM,
psoriasis, OSA; found unresponsive at the hotel where he lives.
He was found between the bed and the wall, unclear how long the
pt was unresponsive. He was initially taken to [**Hospital3 **],
but was transferred here because he was too large to fit in the
scanner. At the OSH ED he was intermittently lucid, tachy to
140s and 88% on RA. He was given IV Narcan for acute AMS w/o
improvement. Nothing else revealing on workup (unrevealing
cardiac enzymes, UA, glucose, Utox and EtOH neg). ABG
7.36/60/60/34 on 4L/NC. WBC 12.6. Ceftriaxone/flagyl for
possible aspiration pneumonia and transferred to [**Hospital1 18**]. In the
[**Hospital1 18**] ED, vitals were T 98, HR 108, BP 136/72, RR 24, 98% on RA.
He was intubated for unclear reasons. Received ceftriaxone,
vancomycin, and acyclovir as empiric coverage for meningitis.
Given flagyl for unclear reasons. LP could not be performed
(?attempted). A CXR showed ?RUL infiltrate. A CT head,
abd/pelvis could not be performed due to size. He was continued
on a dilt drip.
Patient admitted to the [**Hospital Unit Name 153**] on [**3-6**]. Continued on the above
antibiotic regimen. Had CT head, which was negative for acute
bleed. Attempt at LP was unsuccessful (could only hit bone). TTE
performed and uninterpretable due to body habitus. TEE fellow
[**Month/Year (2) 653**] for possible TEE, on hold currently. Weaned off dilt
gtt. Neuro consulted. EEG performed. Woke up and was apparently
violent so placed on propofol.
Patient was recently hospitalized at the [**Location 1268**] VA [**2034-2-19**]
w/ nonexertional CP and tx for CHF exacerbation. Pt's coumadin
was stopped at that time because of being extremely noncompliant
and f/u meds.
Past Medical History:
Congestive heart failure
Atrial fibrillation
Diabetes
Psoriasis
Obstructive sleep apnea
Morbid obesity
Social History:
Patient lives in a hotel. Previously living in his car.
Otherwise unknown.
Family History:
Unknown.
Physical Exam:
On arrival:
General: Intubated, sedated, morbidly obese
HEENT: Sclera anicteric, NC/AT, ETT in place
Neck: supple, JVP difficult to assess due to body habitus
Lungs: Clear to auscultation anteriorly
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, chronic venous stasis changes
Skin: Diffuse psoriatic plaques covering >50% BSA, areas of
excoriation and dried blood
Pertinent Results:
Labs on admission:
[**2124-3-5**] 06:35PM BLOOD WBC-15.2* RBC-4.73 Hgb-12.8* Hct-40.9
MCV-86 MCH-27.1 MCHC-31.4 RDW-16.7* Plt Ct-328
[**2124-3-5**] 06:35PM BLOOD Neuts-84.1* Lymphs-9.3* Monos-5.7 Eos-0.5
Baso-0.3
[**2124-3-5**] 10:10PM BLOOD PT-16.3* PTT-26.5 INR(PT)-1.5*
[**2124-3-5**] 06:35PM BLOOD Glucose-194* UreaN-13 Creat-0.8 Na-148*
K-4.6 Cl-108 HCO3-30 AnGap-15
[**2124-3-5**] 06:35PM BLOOD ALT-29 AST-44* LD(LDH)-275* CK(CPK)-896*
AlkPhos-124* TotBili-0.8
[**2124-3-5**] 06:35PM BLOOD Lipase-19
[**2124-3-5**] 06:35PM BLOOD CK-MB-9 cTropnT-0.01 proBNP-1402*
[**2124-3-5**] 06:35PM BLOOD Calcium-8.6 Phos-4.1 Mg-2.4
[**2124-3-5**] 07:49PM BLOOD Ammonia-86*
[**2124-3-5**] 06:35PM BLOOD TSH-2.3
[**2124-3-5**] 06:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2124-3-5**] 06:49PM BLOOD Glucose-190* Lactate-1.9
.
Chest x-ray [**2124-3-5**]: AP supine chest radiograph is obtained
portably. The patient is quite rotated to his right and motion
artifact significantly limits evaluation. Due to the extreme
limitations of the study, evaluation is deemed non-diagnostic
and repeat study is recommended.
.
CT head [**2124-3-6**]: No evidence of intracranial hemorrhage, edema,
mass effect, or infarction. The ventricles and sulci are normal
in size and configuration. There are no fractures. Visualized
paranasal structures are notable for mucosal thickening at the
sphenoid and ethmoidal air cells, more prominently on the right.
.
EEG [**2124-3-7**]: This is an abnormal routine EEG in the waking and
sleeping states due to the presence of delta frequency slowing
intermixed with a normal background. This finding can be seen
with mild encephalopathy, medication effect, or extreme
drowsiness. There were no focal abnormalities or epileptiform
features noted. Note is also made of an irregular cardiac rhythm
with a tachycardia.
.
CT head [**2124-3-14**]: No hemorrhage or mass effect.
.
CXR [**3-26**]: REASON FOR EXAM: Acute desaturation.
.
Comparison is made with prior study [**3-21**]. Still mild
pulmonary edema has markedly improved. There are linear
atelectasis in the left base. There is mild to moderate
cardiomegaly. There are no enlarging pleural effusions.
.
Brief Hospital Course:
This is a 57 year old male with morbid obesity, OSA, DM, Afib,
CHF, here with altered mental status leading to intubation, now
extubated with improving mental status.
# Altered mental status: Patient was initially found to be
obtunded. This was of unclear etiology. Hypercarbia would not be
wholly unexpected in this patient given his body habitus and his
CPAP requirement. EEG results from [**3-7**] showed abnormal in
waking and sleeping states, with findings which can be seen with
mild encephalopathy, medication effect, or extreme drowsiness.
No focal abnormalities or epileptiform features. MRI was unable
to be performed as patient was too large for scanner. Patient
was treated empirically for meningitis but LP was attempted
multiple times and unsuccessful due to patient's body habitus.
Repeat CT scan to look for cerebral edema or evidence of anoxic
brain injury was negative. Extubated on [**3-12**], mental status
assessed and patient initially alert and able to follow commands
but non-verbal. Did not appear appropriate after extubation
from mental status perspective, and was reintubated shortly
thereafter. Repeat head CT from [**2124-3-14**] was negative. The
patient self extubated on [**3-19**] in the morning with stable
respiratory function post-extubation. At that time he was able
to follow complex commands post-extubation, talking and
responsive. On [**3-21**] he had a new delirium with increased WBC,
diarrhea, and was treated empirically for C. Diff (initially
with flagyl, switched to PO Vanco due to increased diarrhea and
increased WBC count). After being transferred to the floor the
patient was alert and oriented x2 initially. He was found to
be somnolent on the morning after arrival to the floor after not
wearing his CPAP at night. His ABG was not particularly
concerning (7.43/76/47), but his MS improved with 30 minutes of
CPAP, and no other abnormalities were found. His mental status
continued to improve and he remained alert and oriented x3 for
the week prior to discharge.
.
# Respiratory failure:
The patient was intubated in order to protect airway in setting
of altered mental status. It was a difficult intubation using
fiberoptic scope for intubation. He was diuresed aggressively
with lasix due to pulmonary edema (approx 30L over LOS). He was
initially extubated on [**3-12**], however required reintubation with
awake fiberoptic by anesthesia later in the PM on [**3-12**] due to
worsening tachypnea despite BiPAP. Mini-BAL performed [**3-13**] with
no growth on final culture. He was continued with ongoing
diuresis. He had infiltrates on chest x-ray concerning for
ventilator assocaited pneumonia (VAP) given tan colored sputum
and he was started on Vanco/Zosyn. He self extubated on [**3-19**] in
the morning, with stable respiratory status post-extubation. He
is placed nightly on BiPAP prophylactically, and his ABG/VBG??????s
remained stable. He completed a 7 day course of vancomycin/zosyn
and had no further respiratory symptoms on the floor.
.
# Leukocytosis:
His WBC count fluctuated. Elevated WBC at presentation raised
the possibility of infection as cause of AMS. Urine studies were
negative. Possible RUL infiltrate on CXR, however chest x-rays
were poor studies given his body habitus and difficult to
interpret. Sputum culture only with growth of oropharyngeal
flora. Unable to assess for history of meningismus; therefore he
was started on empiric treatment for meningitis. BAL from [**3-13**]
was negative at final culture result. All urine cultures
negative. Blood cultures also negative. Perisistently elevated
WBC counts still have had unclear cause, so he was started on
empiric Flagyl as well on [**3-21**]. On [**3-23**] patient was changed to
PO Vanco when his WBC went up to 20 and his diarrhea worsened.
His WBC count trended down, and his diarrhea resolved. WBC on
discharge was 10.7. He will continue a 14 day course of oral
vancomycin on 4/31/[**2123**].
.
# Atrial fibrillation:
Patient had A-fib with history of RVR. This controlled on oral
diltiazem and this was uptitrated as his BP allowed. He was not
placed on Coumadin due to poor compliance (per review of his VA
records).
.
# CHF:
The patient has a reported history of congestive heart failure.
It was difficult to assess volume status in this patient due to
obesity. He was diuresed aggressively due to his positive fluid
balance and for benefit of his repiratory status. TTE was
attempted but was not readable given his overlying tissue. The
patient was seen by PT and did not require oxygen for
ambulation. Later during his hospitalization he seemed to have
been over-diuresed, so lasix was decreased to 40 mg daily, and
he remained euvolemic on this regimen. Also, lisinopril 5 mg
daily was added to his medications.
# Psoriasis:
The patient has extensive Psoriasis. He was started on topical
creams as recommended in his recent VA discharge summary
(calcipotriene .005% cream [**Hospital1 **] and triamcinolone acetonide .1%
cream [**Hospital1 **]), and his psoriasis improved.
.
# Diabetes:
This was controlled on ISS. He was started on metformin 500 [**Hospital1 **]
and uptitrated to metformin 850 [**Hospital1 **]. Fingerstick blood glucose
was mostly in the 150-200 range prior to discharge. Further
managment may include an increase in metformin or additional of
a sulfonylurea and was deferred to the outpatient setting.
.
#OSA:
Patient required BiPAP at night to prevent hypoxia and
hypercarbia. When he did not wear this his mental status was
altered or he had episodic desaturation. Prior to discharge he
was provided with a BiPAP machine by [**Hospital 6549**] Medical
Company. Request was mailed to [**Hospital1 1474**] VA for records from his
sleep study to be sent to this company.
.
# Disposition:
Social work and case management worked with the patient
extensively to arrange disposition that was both satisfactory to
him and medically appropriate. He was concerned that his
belongings had been lost in the course of his hospitalization
and transfer. The outside hospital and hotel where he had
previously been were [**Name (NI) 653**], and some of his belongings were
found at [**Hospital3 6592**]. He was discharged with the phone
number to that hospital and plans to go pick up his things
there. He was also given clothes, shoes, a cab voucher, and
$43. He will go to a 17 Court Shelter, which has agreed to
accomodate him. His medications will be provided by the VA.
His BiPAP was taken with him. His vital signs and mental status
were stable and, although he was quite reluctant to leave, he
has no further medical indication for hospitalization at this
time.
Medications on Admission:
from recent discharge (VA):
- Lasix 60mg [**Hospital1 **]
- Toprol XL 200mg
- Ocuvite presvervision tab QD
- Hydrocortisone 1% cream, [**Hospital1 **]
- Calcipotriene 0.005% top cream [**Hospital1 **]
- Triamcinilone 0.1% ointment [**Hospital1 **]
- combivent 90/18 - 2puffs q6 prn
- mom[**Name (NI) 6474**] 220mg- 2 puffs qhs
- ASA 81 QD
- Chlorhexidine 4% QD after showering
- Fluoxetine 40mg QD
Discharge Disposition:
Home
Discharge Diagnosis:
-Altered Mental Status
-Hypercapnic Respiratory Failure
-Hospital Acquired Pneumonia
-Psoriasis
-Diabetes Type 2
-Hypertension
-Morbid Obesity
-C. Difficile infection
Discharge Condition:
Hemodynamically stable, afebrile, Alert and oriented to person
and place.
Discharge Instructions:
You were admitted for altered mental status and were treated for
possible Meningitis (brain infection). It is unclear whether you
had Meningitis, and also you had two CT scans of the head which
did not show any cause of altered mental status. You required
intubation to protect your airways and you were treated for
pneumonia while you were on the ventilator. After you came off
the ventilator you did very well. You developed diarrhea and we
treated you for an antibiotic-associated infection. We also
noticed that you became difficult to around when you did not
wear your CPAP at night.
.
We started your application for medical insurance. You should
follow up with ...
.
We made the following changes to your medications:
ADDED Vancomycin take by mouth four times a day until [**Month (only) 547**] ...
You should also continue your topical Psoriasis creams as
written in your medication list.
Please take all your medications as described on your medication
list.
.
It is very important that you wear your CPAP at night. When you
do not wear this, your levels of carbon dioxide rise and this
causes you to have altered mental status which is very
dangerous. If you have any problems with your CPAP machine
please call your doctor immediately.
.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please call the [**Hospital **] hospital and follow up with your PCP [**Last Name (NamePattern4) **] [**12-10**]
weeks.
Completed by:[**2124-4-4**]
|
[
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"518.81",
"997.31",
"428.0",
"427.31",
"250.00",
"428.33",
"278.01",
"584.9",
"276.0",
"348.30",
"327.23",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"38.93",
"96.6",
"96.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
12269, 12275
|
5153, 5331
|
287, 339
|
12486, 12562
|
2915, 2920
|
14107, 14257
|
2363, 2373
|
12296, 12465
|
11847, 12246
|
12586, 13287
|
2388, 2896
|
13316, 14084
|
228, 249
|
367, 2129
|
2934, 5130
|
5346, 11821
|
2151, 2255
|
2271, 2347
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,430
| 164,160
|
44245
|
Discharge summary
|
report
|
Admission Date: [**2112-8-3**] Discharge Date: [**2112-8-24**]
Date of Birth: [**2061-10-4**] Sex: M
Service: NEUROLOGY
Allergies:
Nsaids / Penicillins / Codeine / Tricyclic Antidepressant /
Demerol / Talwin
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
Alteration in mental status.
Major Surgical or Invasive Procedure:
Right hemicraniectomy
History of Present Illness:
The patient is a 50 year old man with a right frontal glioma s/p
resection and recent XRT treatment now presenting with increased
lethargy on [**2112-8-3**]. The patient is unable to give a history so
the details are taken from the chart. The patient was recently
discharged from the [**Hospital1 **] Neurology service on [**2112-7-14**] for a biopsy
and resection of his right frontal mass.
In the interval time, he has been in rehab at [**Hospital1 **] and while
there, he has been noted to be inattentive, disinhibited and
with poor insight, in addition to mild left sided weakness.
However, he typically is interactive and responsive, today the
patient appeared "obtunded" to staff--not responding to
questions or following commands. He did fall to the ground
about 2 days prior after an "aggressive episode of shaking" but
appeared to be at his baseline following that event. No more
seizure activity has been noted. He has not had any infectious
stigmata. His most recent dilantin level was 13.7. He was
transferred to [**Hospital1 18**] ED for further management.
Past Medical History:
-h/o right frontal gliomatosis cerebri
-h/o narcotic abuse
-osteoarthritis
- Hepatitis + A/B/C
Social History:
-lives at [**Hospital1 **]
-at baseline had been walking with a cane
-long h/o tobacco use
-h/o narcotic abuse
Family History:
-not available
Physical Exam:
Exam upon admission:
Vitals: 101.1 97 105/59 97%
General: scar on right frontal area
Neck: supple
Lungs: clear to auscultation
CV: Regular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination upon admission:
eyes closed, will open eyes to loud voice but quickly shuts
them, not following commands, frequently attempts to sit-up,
arms in restraints; pupils appear equally reactive, eye looking
toward right and midline; mild left facial; increased tone on
left; spontaneous mvt x4 but more brisk on right; withdraws to
pain more vigorously on right arm and leg; dtrs, 2+ throughout,
toe up on left, down on right
Pertinent Results:
[**2112-8-3**] 01:02PM BLOOD WBC-11.0 RBC-4.17* Hgb-13.7* Hct-39.7*
MCV-95 MCH-32.8* MCHC-34.5 RDW-14.4 Plt Ct-188
[**2112-8-3**] 01:02PM BLOOD Neuts-83.4* Lymphs-11.4* Monos-4.2
Eos-0.3 Baso-0.8
[**2112-8-3**] 01:02PM BLOOD PT-11.9 PTT-27.1 INR(PT)-1.0
[**2112-8-3**] 01:02PM BLOOD Glucose-120* UreaN-17 Creat-0.8 Na-136
K-3.8 Cl-98 HCO3-24 AnGap-18
[**2112-8-3**] 01:02PM BLOOD ALT-123* AST-105* CK(CPK)-134
AlkPhos-124* Amylase-37 TotBili-0.7
[**2112-8-3**] 01:02PM BLOOD Albumin-4.2 Calcium-9.1 Phos-4.4 Mg-2.1
[**2112-8-3**] 01:02PM BLOOD Phenyto-9.9*
CT HEAD W/O CONTRAST ([**2112-8-3**])
FINDINGS: There is no acute intracranial hemorrhage. Subfalcine
herniation is again identified, but has increased now with
approximately 11 mm of leftward shift, previously 9 mm.
Right-sided uncal herniation also is present. There is also
increasing effacement of the quadrigeminal plate cistern
consistent with transtentorial herniation. The previously seen
area of possible hemorrhage in the right frontal lobe, likely
the biopsy site, has since resolved. A small amount of low
attenuation fluid is seen in that area related to
post-interventional changes. The large right frontal lobe lesion
is difficult to see on this study, compared with prior MR study,
but is likely unchanged.
Patient has undergone prior right-sided parietal craniotomy and
there is also a prior burr hole present in the right frontal
bone. Osseous structures are otherwise unremarkable. Minimal
circumferential mucosal thickening is seen in the right
maxillary sinus, and a minimal amount of mucosal thickening in
the antrum of the left maxillary sinus. Remaining visualized
paranasal sinuses and mastoid air cells are clear. Soft tissues
are unremarkable.
IMPRESSION:
1. Worsening right-to-left subfalcine herniation, and new
right-sided uncal herniation and transtentorial herniation.
2. No acute intracranial hemorrhage.
CT HEAD W/O CONTRAST ([**2112-8-5**])
FINDINGS: The study is compared with most recent non-contrast CT
examination dated [**8-4**], as well as a series of studies dating to
[**2112-6-29**]. Since yesterday's examination, the patient has
undergone right hemicraniectomy with decompression, with
expected postoperative pneumocephalus and extra-axial hemorrhage
at the site of the surgical defect. There is persistent 8 mm
leftward shift of the septum pellucidum (this measured 11 mm,
previously), with subfalcine herniation, effacement of the right
and "trapping" of the left lateral ventricles. However, there
has been significant improvement in the degree of right uncal
herniation with improvement in the appearance of the basilar
cisterns, indicative of improvement in the degree of downward
transtentorial herniation. The cerebral aqueduct and fourth
ventricle remain uneffaced, and there is no evidence of
tonsillar herniation. The poorly defined, infiltrative large
mass centered in the deep [**Doctor Last Name 352**] matter of the right frontal lobe
remains relatively occult on CT examination.
IMPRESSION: Right hemicraniectomy and decompression with
significant improvement in right uncal and downward
transtentorial herniation, persistent subfalcine herniation with
trapping of the left lateral ventricle.
CT HEAD W/O CONTRAST ([**2112-8-8**]):
FINDINGS: Comparison with the prior study shows continued
extensive right to left subfalcine herniation and accompanying
compression of the right lateral ventricle. There appears to be
very little change in the extent of contralateral left lateral
ventricular dilatation. There is no evidence for the presence of
intracranial hemorrhage that has developed since the prior
study.
CONCLUSION: Stable, grossly abnormal study.
[**2112-8-3**]:
AP portable upright view. The left lateral hemithorax is not
fully included on the image. This study is further limited by
motion. A patchy opacity in the left lower lobe likely
represents pneumonia. There is no evidence of a left pleural
effusion, and no right pleural effusion. The right lung appears
clear. There is no pulmonary edema. Cardiac and mediastinal
contours are stable. The imaged bones appear unremarkable.
Surgical clips are present in the right upper quadrant of the
abdomen.
IMPRESSION: Left lower lobe pneumonia. Given the limitations of
the study, further evaluation by PA and lateral views is
suggested
EEG ([**2112-8-4**]):
FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
remained
slow and disorganized, typically reaching a [**7-20**] Hz maximum in
most
areas.
ABNORMALITY #2: There were additional bursts of generalized
slowing.
There were also occasional bursts of additional delta slowing in
the
right frontal region or left temporal region, but these were
minimal.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient appeared to remain awake or drowsy throughout
most
of the record. No stage II sleep was obtained.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathic condition affecting both cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There were a few
bursts of
focal slowing but no areas of persistent focal slowing. There
were no
epileptiform features.
NCHCT [**8-12**]: 1. Extensive right to left subfalcine herniation
and compression of the right lateral ventricle, which was seen
on the prior examination. There is no new intracranial
hemorrhage.
Brief Hospital Course:
Mr. [**Known lastname **] is a 50yo man with h/o glioblamotosis cerebri who
presented with altered mental status and for radiation treatment
for his tumor.
1. Altered mental status: Pt was admitted to the NeuroICU and
started on dexamethasone and mannitol for herniation. He also
received a 500mg bolus of intravenous dilantin. By the next
morning, he was much more awake, oriented, and following
commands. He appeared to be back to his baseline. His repeat
head CT showed some mild improvement, but he continued to have
significant edema with midline shift from right sided
gliomatosis cerebri. His medications were continued without
problems. [**Name (NI) **] then went for a hemicraniectomy on the right in
order to provide decompression on [**2112-8-5**] by Dr. [**Last Name (STitle) **]. This
was done because he will continue to receive XRT and chemo which
will likely result in more swelling in the future. He tolerated
the procedure well and was quickly extubated after returning to
the ICU from the OR. After surgery, he had significant facial
edema, but his mental status and level of consciousness were
back to his baseline. Mannitol was slowly weaned. He was
transferred to the floor on post-op day three where he remained
stable until discharge. After he passed his speech and swallow
evaluation, keppra was added as a prophylactic anticonvulsant.
He is now at a theraputic dose of keppra 1000mg [**Hospital1 **]. The
phenytoin is being tapered, now at 100mg [**Hospital1 **], and plan to
decrease to 100mg qday tomorrow and then off,as it will decrease
the bioavailability of his chemo. He received his first
planning session and first dose of WBXRT today on the OMed
service. He will be transferred back to [**Hospital1 **] where he will
continue WBXRT with temodar given one hour before XRT. Decadron
will be continued during XRT because of risk of increased
swelling. He will see Dr. [**Last Name (STitle) 4253**] one month after discharge
and should schedule an MRI for that time as well.
Exam on discharge: awake, alert, fluent, some disinhibition,
mild inattention (digit span forwards [**5-18**]), no neglect, mild
left hemiparesis (delt at least antigravity, provides resistence
in other UMN muscle groups). He was started on Zyprexa to help
with agitation which is likely secondary to decadron and frontal
lobe location of the tumor.
Of note, the CSF fluid collection on the right side of his head
may increase in size in response to radiation. Should this
happen, he should be kept in a seated position as long as
possible throughout the day to decrease swelling and increase
the likelihood of his helmet fitting. Additionally, his mental
status is stable (waxes and wanes between oriented x 1 and x 3)
and he is afebrile. CRP 4.6, ESR 29. He does require a sitter
at all times for his mental status and should wear his helmet at
all times (especially when OOB. if sitter can reliably keep him
in bed may remove helmet).
2.LLL pneumonia: The patient was found to have a LLL pneumonia
on CXR on admission. Given that he was at a hospital when this
developed, he was started on vancomycin and ceftazidime to cover
for MRSA, typical CAP bacterium, and pseudomonas. He was
treated witha total of a ten day course of antibiotics. He had
essentially normal WBC counts here. His initial fever also
resolved on antibiotics. No other source of infection was found
and blood cultures were negative. As he has been on high dose
decadron for approximately one month, we started Bactrim for PCP
[**Name Initial (PRE) 1102**].
3. S/P right hemicraniectomy: As above, the pt underwent a
decompressive hemicraniectomy on the right. His bone flap is
stored at [**Hospital1 18**] and will likely be re-attached in [**2-15**] months to
allow for swelling with radiation. He should wear the helmet
provided for him when out of bed (really at all times if pt may
get out of bed without warning given his mental status).
4. Oral Thrush: Pt has been maintained on clotrimazole toches
QID to treat oral thrush.
The patient is discharged to [**Hospital **] Rehab. He requires a
sitter at all times. His mental status waxes and wanes but he is
at risk for falls, and for this reason should wear his helmet
certainly when OOB, and if possible at all times. He will
continue with his chemotherapy/radiation treatment, for which he
should be brought to [**Hospital1 18**]. He should receive Temodar as
prescribed one hour before all radiation treatments. He will
follow up with Dr. [**Last Name (STitle) 4253**].
Medications on Admission:
-methadone
-dilantion 100 tid
-protonix
-nicotine
-dexamethasone 3 mg tid
-temodar
Discharge Medications:
1. Methadone 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
2. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for T>101.5.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 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. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day) for 2 days: Please give [**Hospital1 **] today
([**2112-8-24**]), then only qday tomorrow [**2112-8-25**], then stop. Tapering
off.
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
Disp:*1 ML(s)* Refills:*3*
10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
WEEKLY () for 4 weeks.
Disp:*4 * Refills:*0*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Zyprexa Zydis 10 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO at bedtime.
14. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
15. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
17. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
19. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed.
20. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for PCP [**Name Initial (PRE) 1102**].
22. Dolasetron 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) while receiving chemotherapy.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-gliomatosis cerebri
-s/p right hemicraniectomy
-left lower lobe pneumonia
- Hep A/B/C
Discharge Condition:
Stable. Neurologic examination notable for left facial droop,
mild left hemiparesis. Patient requires use of helmet at all
times when out of bed, as he is s/p hemicraniectomy
Discharge Instructions:
Please continue all medications as prescribed. Note that we are
tapering dilantin - please give [**Hospital1 **] today [**2112-8-24**] and qday
tomorrow [**2112-8-25**], then discontinue dilantin.
Please attend all follow-up appointments. Please be sure to give
pt his Temodar chemotherapy by mouth one hour prior to all
radiation appointments.
If you experience worsening weakness, numbness, speech or visual
difficulties, or other concerning symptoms, please return to the
emergency department for evaluation.
Use helmet at all times when out of bed
Followup Instructions:
Please return to [**Hospital1 18**] for scheduled radiation therapy. Please
give Temodar by mouth one hour prior ot all radiation
treatments.
Neuro-oncology: Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD
Phone:[**Telephone/Fax (1) 1844**], one month from discharge. At the time you
make the appointment, please schedule an MRI.
|
[
"507.0",
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"285.9",
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"112.0",
"191.0",
"715.90",
"070.70",
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] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.25",
"38.93",
"92.29",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
15077, 15156
|
8145, 8313
|
366, 389
|
15287, 15464
|
2492, 8122
|
16068, 16432
|
1759, 1775
|
12824, 15054
|
15177, 15266
|
12716, 12801
|
15488, 16045
|
1790, 1797
|
298, 328
|
417, 1496
|
10189, 12690
|
2067, 2473
|
8328, 10170
|
1518, 1615
|
1631, 1743
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,236
| 156,425
|
52424
|
Discharge summary
|
report
|
Admission Date: [**2195-3-26**] Discharge Date: [**2195-4-10**]
Date of Birth: [**2112-2-19**] Sex: F
Service: MEDICINE
Allergies:
Belladonna Alkaloids / Flagyl
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo f with hx of DVT/PE on lovenox, and predinsone for
myelodysplastic syndrome, was admitted due to fall resulting in
tramatic injury. Pt is [**Name (NI) 595**] speaking and story is per
daughter. Pt was heard yelling in her room and found on the
ground. She had slipped out of bed. She was bleeding and taking
to ER. Pt fell on her right side. Per daughter pt is bedridden
for last several months. Unclear why. Last left the house months
ago by ambulance. House has no stairs. Daughter could not
clarify why pt is unable to use wheelchair. Pt was in pain and
did not want to answer questions. Daughter was very defensive
and was also recluctant to answer questions about her mother's
home life. She states she would like her vision checked while in
the hospital. She reports her mom lost the vision in her left
eye 2 months ago, but has not seen a doctor. bed to fall,
mechanical, not witnessed, fall on head and right side. Per her
pt takes many of her medications on a prn schedule. But she has
been taking her lovenox and prednisone.
.
In the ER VS were HR 100 151/69 16 97. Pt had a deep lacteration
on her right arm, requiring plastics to repair it. Also skin
tear on right leg and bruise on right forehead. Pt had ortho
consult, brace was placed on right knee. Pt has non-opearable fx
of right femur extending to knee joint and fx of right elebow.
Pt refused morphine and had nausea. Pt was given zofran and
600mg IVF. VS on transfer were VS: 98.1 102 100/60 16 95% 3
Liters.
.
Since admission, patient seen by Orthopedics who thought she her
femur was non-operative and she was placed in a knee-immobilizer
(to be worn at all times); her right elblow was wrapped in an
ACE bandage. Plastics was consulted and sutured her RUE and LLE
lacerations in two layers. They recommended Ancef for 7 days, to
keep the dressing on for 4-5 days (Plastics to remove) and
Vitamin A supplementation. On [**3-26**] she was transfused 2U PRBC
with suspicion of enlarging thigh hematoma. Social Work was
consulted to evaluate for potential elder abuse/neglect. She was
also noted to have new ARF (Bactrim d/c'd) and was treated with
IVF and PRBC. Renal consulted and following. Opthamology was
consulted given her known vision deficits; they recommended
continuing her current home medications. Renal U/s revealed no
hydronephrosis, small non-obstructing stone in the right kidney.
Renal consult thought pre-renal status should be avoided.
Patient developed diarrhea and was started on Ciprofloxacin
[**2195-3-31**]. On [**2195-4-2**] both Ciprofloxacin and Cephazolin were
discontinued and Ceftriaxone was started. She has had no
positive culture data since admission. Pain has been controlled
with Tramodol, scheduled Tylenol and morphine PRN.
.
On [**2195-4-2**] patient was Triggered for marked nursing concern. Her
initial ABG was 7.06 / 91 / 75. Per discussion with the family,
the patient is generally on CPAP at night for OSA. She was then
started on CPAP on the floor in an attempt to keep the patient
on the floor after extensive discussion with her daughter about
goals of care. After CPAP for many hours, VBG failed to improve
and she was then transferred to the ICU for BiPAP.
.
Upon initial floor [**Date Range 2742**], patient does not respond to her
name. When her friend speaks to her in [**Name (NI) 595**] she will only nod
that she can hear her but will not respond to questions
involving pain or any other symptoms.
.
Past Medical History:
Anemia with baseline Hct 26-32, felt to be due to CKD, anemia of
chronic disease, and myelodysplastic syndrome
h/o GI bleeds
h/o repeated admissions for dyspnea and altered mental status
h/o hypercarbia requiring biPAP 13/5 with 0.5-2.5L oxygen by NC;
unclear if due to obesity hypoventilation or OSA or COPD
CAD s/p NSTEMI '[**89**]
Chronic diastolic CHF EF 60-70's
h/o hyperkalemia
MDS
Crohn's disease
CKD with baseline Cr 1.9-2.1 (was last 1.5 when checked [**9-/2194**])
h/o DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin but stopped due to GI bleed
PICC associated LUE DVT and hematoma [**5-8**] (seen also in [**7-/2194**])
Chronic b/l LE edema
Breast cancer s/p lumpectomy & XRT
GERD
Intracranial bleed and fx after pedestrian vs car 20 yrs ago
Cataracts
Venous stasis dermatitis
Tinea pedis
h/o "arrhythmia" which daughter says is tx with metoprolol in
past
s/p cholecystectomy
Social History:
[**Year (4 digits) 595**] speaking only. Married; lives with her daughter [**Name (NI) 108329**],
[**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. [**Name (NI) 108329**] is the caretaker
for both of her parents. Has daily visiting nurse at home. Pt
bedridden per daughter since [**12-7**].
Family History:
Non-contributory
Physical Exam:
95.6 (axillary), 102/49, 70, 28, 92/CPAP Autoset , 1070/270
General: Minimally responsive, will nod when spoken to in
[**Month (only) 595**] but does not answer questions about symptoms
[**Month (only) 4459**]: Sclera anicteric, MMM
Neck: supple, no LAD; JVP at 2cm above clavicle
Lungs: Clear to auscultation bilaterally anteriorly
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur but difficult to auscultate over breath sounds
Abdomen: soft, mildly distended does not grimace to palpation,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, large bandage on right arm
with eccymoses in R shoulder, and brace on right leg, bandages
on both lower extremities with 2+
Neuro: follows commands, hard of hearing
Pertinent Results:
BLOOD GASES:
[**2195-3-30**] 02:30AM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-192* pCO2-79*
pH-7.15* calTCO2-29 Base XS--3 Intubat-NOT INTUBA
[**2195-4-2**] 12:47PM BLOOD Type-CENTRAL VE pH-7.07* calTCO2-
Comment-GREEN TOP,
[**2195-4-2**] 01:45PM BLOOD Type-ART pO2-75* pCO2-91* pH-7.06*
calTCO2-27 Base XS--7 Intubat-NOT INTUBA
[**2195-4-2**] 05:12PM BLOOD Type-[**Last Name (un) **] Temp-36.6 pH-7.09* Comment-95.8
AXILL
[**2195-4-3**] 03:28AM BLOOD Type-MIX Temp-37.2 pO2-44* pCO2-60*
pH-7.22* calTCO2-26 Base XS--4
[**2195-4-3**] 12:28PM BLOOD Type-[**Last Name (un) **] Temp-37.4 Rates-/28 O2 Flow-3
pO2-51* pCO2-75* pH-7.14* calTCO2-27 Base XS--5 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2195-3-30**] 02:30AM BLOOD Lactate-0.8
[**2195-4-2**] 12:47PM BLOOD Lactate-0.8 K-5.5* calHCO3-25
[**2195-4-2**] 05:12PM BLOOD Lactate-1.0 calHCO3-24
[**2195-4-3**] 03:28AM BLOOD Lactate-1.7
Brief Hospital Course:
MICU COURSE:
# Hypercarbic Respiratory Failure: Transferred to ICU for
worsening hypercarbic respiratory failure with an ABG
7.22/44/60/26. Patient with history of chronic hypoventilation.
CXR concerning for new left sided PNA vs atelectatic changes vs
positional. Possible contribution of narcotics in context of
recent injury. Patient placed on BIPAP with significant
improvement in blood gas to 7.14/51/75/27 @ 30% FiO2.
During her ICU course, she continued to have episodes of hypoxia
and required noninvasive ventilation. She was maintained on
broad spectrum antibiotics. As discussed with her daughter and
health care proxy, she was DNR/DNI, no pressors. She was placed
on BiPap intermittently which became very uncomfortable. In
light of her worsening respiratory status, renal failure,
unrelieved on Bipap, the decision was made on [**4-10**] to stop
noninvasive ventilation. The patient ultimately passed away
# Hypotension: Newly the day of transfer to the ICU. The night
prior was given Lasix IV x 2 the day prior. Some concern for
hypovolemia (but minimal urine output which limits bolusing)
Concern for possible infectious sepsis. She was started on
broad spectrym antibiotics with good coverage of skin flora due
to the fact that she had multiple wounds. She was supported
with fluid as needed as well as antibiotics. Her hypotension
improved initially, however ultimately worsened. Despite fluid
and blood as needed, she continued to have respiratory
compromise.
# Fall with mulitple fractures and laceration: Intraarticular
right knee/femur fracture and right elbow fracture with
associated head injury and deep laceration to right arm and tear
of left leg. Patient became more sleepy with oxycodone, so this
was discontinued. She was treated with antibiotics and dressing
changes. She elected not to have any surgery.
# AMS: Suspect multifactorial including toxic-metabolic
abnormalities (hypercarbia, infection); hospital delirium and/or
infection that is being untreated. As above, she was treated
with antibiotics and noninvasive ventilation. She was
responsive to her daughter and during the admission had several
days during which she was able to eat and converse. Ultimately
as her respiratory status declined, she became more somnolent.
# Acute on chronic renal failure: Cr improved to 2.8 today. Per
renal, somewhere between pre-renal and ATN. Renal ultrasound
without hydronephrosis. her medications were renally dosed and
despite efforts to treat her multiple medical problems, her
renal failure worsened.
# Crohn's: stable during admission
.
# Hx of PE/DVT: last DVT [**5-8**] with PICC. Was on lovenox at home,
but now concern for bleeding in setting of significant
laceractions and fractures. Lovenox was held, she was on heparin
intermittently, however due to dropping Hct, this was also DC'd.
On [**2195-4-10**] the decision was made with her HCP to stop
noninvasive ventilation as it was not effective. Her
hypotension worsened as did her respiratory drive. She expired
at [**2210**]. On exam, her pupils were fixed and no breath sounds or
heart rhythm could be auscultated, no pulses palpable.
Medications on Admission:
Brimonidine drops
Bactrim - unclear how often pt is taking
[**Name (NI) 108336**] drops [**Hospital1 **] in left eye
B12 1000mcg monthly
Lovenox 60 Qday
Epo [**Numeric Identifier **] units qweek
Folate 1mg daily
Lasix 10mg prn- took 3 days ago
Mesalamine 1200mg prn
Nystatin cream [**Hospital1 **] prn
Omeprazole 20mg [**Hospital1 **]
Oxygen 2liters NC (86-88%RA)
Prednisone 20mg qday
Timolol 0.5% gtt Left eye [**Hospital1 **]
Triamcinolone 0.025% cream [**Hospital1 **] for venous stasis prn
Calcium unsure dose
Magnesium unsure dose
Miconazole 2% powder prn
Probiotic 2 per day
Artificial tears
Kayexalate prn 15g most days
Cipro- unsure dose
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxia, PNA/COPD, ARF, Falls
Discharge Condition:
Pt. expired
Discharge Instructions:
Pt. expired
Followup Instructions:
Pt. expired
|
[
"585.9",
"799.02",
"285.1",
"285.21",
"276.7",
"428.0",
"486",
"787.91",
"276.0",
"880.03",
"518.81",
"785.52",
"707.03",
"238.75",
"276.2",
"530.81",
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"813.05",
"038.9",
"403.90",
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"995.92",
"496",
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"V12.79",
"E884.4",
"428.32",
"584.9",
"414.01",
"327.23",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10678, 10687
|
6822, 9981
|
295, 301
|
10761, 10775
|
5886, 6799
|
10835, 10850
|
5048, 5066
|
10708, 10740
|
10007, 10655
|
10799, 10812
|
5081, 5867
|
251, 257
|
329, 3762
|
3784, 4703
|
4719, 5032
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,821
| 138,868
|
49450
|
Discharge summary
|
report
|
Admission Date: [**2143-10-30**] Discharge Date: [**2143-11-6**]
Date of Birth: [**2073-3-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3948**]
Chief Complaint:
Bilateral Malignant pleural effusion
Major Surgical or Invasive Procedure:
[**2143-10-30**] Left thoracoscopy and pleurodesis, and chest tube
placement.
[**2143-10-31**] Right thoracoscopy and creation of pericardial window.
Drainage of pleural effusion.
[**2143-11-1**]: Talc Pleurodesis, Right
History of Present Illness:
Mrs. [**Known lastname **] caries a diagnosis of breast cancer, initially
diagnosed in [**2112**] with multiple surgical and medical therapies
throughout the years, recently started on Taxotere. She started
experiencing progressive dry cough and SOB a few weeks ago and
underwent a CT scan of the chest which revealed bilateral
pleural effusions in addition to pericardial effusion. She
underwent bilateral thoracentesis and both effusions were
positive for malignancy. she presents today for left
thoracoscopy and pleurodesis.
Past Medical History:
Right radical mastectomy for breast Cancer [**2112**]
left simple mastectomy for breast Cancer
Paralyzed vocal cord with mediastinal mass [**2135**]
Tracheostomy for respiratory compromise secondary to etastatic
disease with tracheal compression.
Depression
GERD
Social History:
Lives on [**Location (un) **] with her husband who is very supportive
Family History:
non-contributory
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the hospital on [**2143-10-30**] for bipleural
effusions and an
enlarging pericardial effusion. She underwent left thoroscopy,
with pleurodesis,
and chest tube placement on [**10-30**]. On [**10-31**] she underwent
pericardial window for
pericardial effusion with right thoroscopy and right pleural
effusion
drainage. On [**11-3**] at 0030 the patient noted to be in atrial
flutter with
HRs in 140s. She was asympatomic at that time. She was given
lopressor 5 mg IV x 2 with drop in SBP to 70s and she was
transferred to ICU. Upon arrival to ICU she spontaneously
converted to normal sinus rhythm. On [**11-4**] she underwent pigtail
catheter placement of R pleural effusion. She remained stable in
the ICU and was called out to the floor the evening of [**11-4**]. At
0500 [**11-5**] patient reverted back to typical atrial flutter at
with
AV conduction from 2:1 to 4:1. She was sleeping at the time and
was asymptomatic. She received 5 mg IV lopressor x 2 with SBP
drop to 70s and transient decrease in HR.
Ms. [**Known lastname **] has no prior history of atrial flutter or fibrillation.
This may have been precipitated by multiple recent invasive
pulmonary interventions as well as her recent pericardial window
and likely pericardial inflammation.
Cardiology was consulted at the second recurrence of atrial
flutter during this hospitalization.
Attempts at rate control with metoprolol have been met by
hypotension and little response in rate. Given her
limited life expectancy and apparent symptomatic atrial
fibrillation, it was recommended to rhythm control with
amiodoarone.
Furthermore, given her most recent invasive procedures, a full
therapeutic anticoagulation wasn't considered to be optimal for
her at this time point.
She was switched on [**2143-11-6**] to 200 mg amiodarone three times a
day for one week, which will be followed by 200 mg amiodarone
two times a day for another week and finally will be converted
to a dose of 200 mg amiodatone once per day.
Upon discharge Ms [**Known lastname **] is back to sinusrhythm with a heart rate
between 70 and 80 bpm.
Medications on Admission:
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - 20 mg Tablet - one Tablet(s) by mouth 20mg in am-
PREGABALIN [LYRICA] - 150 mg Capsule - 1 Capsule(s) by mouth
twice a day
PROCHLORPERAZINE [COMPAZINE] - 10 mg Tablet - 1 Tablet(s) by
mouth prn
RANITIDINE HCL [ZANTAC] - 300 mg Tablet - 1 Tablet(s) by mouth
at bedtime
LORATADINE -10 mg Tablet - 1 Tablet(s) by mouth daily
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER]
OMEPRAZOLE - 20 mg Tablet, 1 Tablet(s)by mouth Twice a day
SENNA
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Bilateral Pleural effusions
Discharge Condition:
stable
Completed by:[**2143-11-12**]
|
[
"197.0",
"423.8",
"997.1",
"693.0",
"E942.6",
"478.30",
"457.0",
"511.81",
"276.1",
"427.32",
"V45.71",
"197.2",
"197.7",
"V15.3",
"197.1",
"E878.8",
"V10.3",
"458.29",
"E933.1",
"427.31",
"V87.41",
"357.6",
"354.9",
"244.9",
"198.5",
"292.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"34.06",
"34.92",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
4321, 4382
|
1573, 3702
|
359, 582
|
4454, 4493
|
1532, 1550
|
4403, 4433
|
3728, 4298
|
282, 321
|
610, 1142
|
1164, 1429
|
1445, 1516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,970
| 126,530
|
40884
|
Discharge summary
|
report
|
Admission Date: [**2149-5-5**] Discharge Date: [**2149-5-21**]
Date of Birth: [**2067-2-28**] Sex: F
Service: MEDICINE
Allergies:
Terbutaline / Dicloxacillin / Advair Diskus / Codeine /
Penicillins / Zantac / Fosamax / Heparin Agents / Ativan /
Percocet / Vancomycin / Glucocorticoids (Corticosteroids) / Ace
Inhibitors / Amoxicillin / alendronate sodium / NSAIDS
Attending:[**First Name3 (LF) 2248**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
82 yo F with history of CAD s/p MI in [**2117**], angina, history of
stents to LAD and LM ([**4-23**]), HTN, HL, PVD, AAA s/p repair, CEA,
CKD (Cr 2.5), severe pulmonary hypertension, HIT, history of PE,
and oxygen-dependent COPD who is transferred from [**Hospital1 4494**] with hypoxia. Patient was hospitalized at [**Hospital1 18**] from
[**4-22**] - [**5-1**] for a planned coronay catheterization and underwent
stenting w/ DES of her left main (known distal 70% stenosis) and
LAD (mid 80% in-stent restenosis (ISR) and a distal 50%
stenosis). Patient experienced persistent angina and underwent
repeat catheterization to assess possible occlusion of her LCX
(known 30% and 60% lesions on initial cath), which showed patent
stents and stable LCX lesions and no further interventions were
done. Continued angina and DOE were attributed to combination of
COPD and small vessel disease. CXR two days prior to discharge
([**4-29**]) was notable for b/l pleural effusions and moderate to
severe pulmonary edema. She was discharged on lasix 20 mg PO
daily w/ the addition of amlodipine to her regimen to [**Hospital 1514**]
Health Care Center for cardiopulmonary rehab.
.
At rehab, patient noticed progressive SOB and episodes of angina
with movement- severe episode prior to admission on route to
bathroom prompting her to call nurse [**First Name (Titles) **] [**Last Name (Titles) **] ambulance.
Denies fevers, chills, cough, nausea, or vomiting. Presented to
[**Hospital3 3765**] where initial vitals were T 98.4, BP 122/53, HR
91, RR 22 and O2 sat 73% on RA. Labs showed WBC 8.8 w/ 73.6%
neutrophils, hct 38.1, plts 142, creatinine 2.9 and BUN 35. BNP
442, Troponin was 0.04, CK 64. ABG showed pH 7.43 pCO2 39, pO2
44. EKG showed SR w/ occ PVCs and RBBB, q waves in lead III
unchanged from prior. CXR showed significant left pleural
effusion, mild effusion at right base, and fluid w/in fissure.
Patient was given duoneb with minimal improvement, lasix IV x1
(dose not documented in OSH paperwork), maintained on CPAP, and
transferred to [**Hospital1 18**] on a non-rebreather for further management.
.
In the CCU, patient reported she felt comfortable. Denied CP,
SOB, nausea, or vomiting. Reported a leg cramp, which she notes
she gets intermittently. Notes productive cough (unable to
expectorate) for past two to three weeks. No fevers or chills.
.
On review of systems, s/he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, dysurea, black stools or red stools. S/he denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC HISTORY: +Hypertension +Dyslipidemia -Diabetes
-Coronary Artery Disease s/p MI in [**2117**]
-CABG: None (Declined [**3-24**])
-PERCUTANEOUS CORONARY INTERVENTIONS: RCA/LAD stents in [**2140**] by
Dr. [**Last Name (STitle) 2257**] ([**Hospital1 3494**]); and LMCA and LAD [**2149-4-23**] at [**Hospital1 18**]
-PACING/ICD: None
2. OTHER PAST MEDICAL HISTORY:
- PERIPHERAL VASCULAR DISEASE
- HISTORY TOBACCO USE
- ? History of HIT
- Rectal Cancer
- COPD (oxygen dependent- 2 L/min at night and increase to 3
l/min with activity)
-Chronic kidney disease (Baseline Cr 2.5-2.9) secondary to renal
hypoplasia
- History of pulmonary embolism ([**Hospital1 197**] d/c-ed during last
hospitalization [**4-23**] after discussion w/ PCP)
-Thyroid disease
-Iron deficiency anemia
-PULMONARY HYPERTENSION (PA systolic pressure estimated by ECHO
[**9-22**] calculated from peak TR velocity is 45 to 75)
-Abdominal Aortic Aneurysm
-s/p CAROTID ENDARTERECTOMY
-DEPRESSIVE DISORDER
Social History:
Lives at [**Hospital3 **] facility in [**Location (un) 1514**]. Most recently in
cardiopulmonary rehab.
-Tobacco history: quit smoking in [**2128**], 30 pack-years
-ETOH: Denies usage
-Illicit drugs: none
Family History:
Strong family history of CAD and cardiac death before age 50.
Father died from MI at age 45.
Physical Exam:
ON ADMISSION:
GENERAL: Elderly woman breathing comfortably, able to speak in
full sentences with non-rebreater in place; Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry mm.
NECK: Supple with JVP at clavicle at 45 degrees, appx 3 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR with frequent ectopy, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Distant BS throughout, decreased breath sound in b/l
bases; faint crackles in bases, but no ronchi or wheezes
ABDOMEN: Soft, NTND. Active BS, well healed incisional scar with
reducible hernia. No HSM or tenderness.
EXTREMITIES: Trace pedal edema. No c/c. No femoral bruits. Cool
LEs.
SKIN: Numerous ecchymoses. No stasis dermatitis, ulcers, scars,
or xanthomas.
PULSES:
Right: DP dopplerable PT absent
Left: DP absent PT dopplerable
.
On discharge:
GENERAL: Sitting in chair, NAD. Breathing comfortably
HEENT: PERRL, EOMI. mild pallor, no cyanosis. MM moist
NECK: No JVD sitting in chair.
CARDIAC: Irregular RR frequent premature beats, normal S1, S2.
No m/r/g. No S3 or S4.
LUNGS: [**Month (only) **] at bases, L>R, air movement somewhat worse today. No
wheezes or crackles.
ABDOMEN: Soft, NTND. BS ++, surgical scar with reducible hernia.
EXTREMITIES: No c/c. no edema.
SKIN: Numerous ecchymoses on upper limbs.
Pulses: Feet warm.
Pertinent Results:
ON ADMISSION:
OSH LABS:
WBC 8.8 w/ 73.6%N; Hct38.1 Plt 142, MCV 94.6
Na 140 K 3.8 Cl101 HCO328 BUN35 Cr2.9 Mg2.5 Ca9.4 TP 7.0 Alb3.8
ALK 123 AST29 ALT21
Troponin 0.04; CPK 107, CKMB 2.9, Index 2.71
BNP 442
ABG: pH 7.43 CO2 39 O2 44 A/a Gradient 270
UA: Yellow, cloudy, Neg for bili, ketone, blood, protein, urob,
nitrite; trace Leuk est; [**5-23**] WBC; RBCs 0-1; Bacteria: Many
[**Hospital1 18**] LABS:
[**2149-5-7**] 02:20AM BLOOD WBC-10.1 RBC-3.70* Hgb-11.6* Hct-34.8*
MCV-94 MCH-31.4 MCHC-33.4 RDW-16.4* Plt Ct-140*
[**2149-5-8**] 05:35AM BLOOD Glucose-109* UreaN-34* Creat-2.6* Na-139
K-3.9 Cl-104 HCO3-25 AnGap-14
[**2149-5-8**] 05:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2
STUDIES:
[**5-5**] EKG (OSH): Sinus rhythm at 84 bpm w/ PVCs. Q wave in III
and RBBB. TWI in II, III, AVF, V1-V3 c/w prior.
[**5-5**] EKG ([**Hospital1 18**]): Sinus rhythm at 80 bpm with RBBB and Q wave in
III. TWI in III, AVF, V1-V3 c/w baseline. (Sinus rhythm with
ventricular premature beats. Intra-atrial conduction delay.
Right bundle-branch block. Inferior and precordial lead ST-T
wave changes may be primary and are non-specific. Clinical
correlation is suggested. Since the previous tracing of [**2149-4-29**]
there is probably no significant change.)
[**5-5**] CXR: In comparison with the study of [**4-29**], there is
continued
hyperexpansion of the lungs with substantial, though probably
slightly
decreasing, left pleural effusion. Small right effusion is seen.
Moderate
cardiomegaly persists with some elevation of pulmonary venous
pressure. No
definite acute focal pneumonia.
[**5-5**] B/L LENIS: No evidence of DVT.
[**5-6**] TTE: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. 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%). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. Trace aortic regurgitation
is seen. The mitral valve leaflets are structurally normal. Mild
to moderate ([**12-15**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
[**5-6**] CXR (RT AND LEFT LATERAL DECUBITUS): Pleural thickenings
probably organized as they do not change significantly in
decubitus positions from what has been observed earlier.
[**5-8**] CHEST CT (NON CON): 1. Mild to moderate centrilobular
emphysema.
2. Bilateral pleural effusions, larger on the left side than on
the right
associated with marked left lower lobe atelectasis.
3. Peripheral opacity in the right lower lobe, which may
represent focal
pneumonia or aspiration, although an infarct is also considered
possible in the appropriate clinical setting.
4. Ground-glass opacity accompanied by mild interstitial
thickening and
fissural fluid suggestive of pulmonary edema.
[**5-19**] R Heart Cath: FINAL DIAGNOSIS:
1. Severe pulmonary hypertension.
2. Normal left and right sided filling pressures.
3. Mild (17% drop0 in PVR following administration of NO.
4. Recommendations as per primary cardiology team.
DISCHARGE LABS:
[**2149-5-21**] 06:05 7.1 3.87* 11.7* 35.9* 93 30.1 32.5 15.2 198
[**2149-5-21**] 06:05 21.2* 1.9*
[**2149-5-21**] 06:05 971 32* 2.5* 147* 3.5 99 34* 18
[**2149-5-13**] 15:31 ART 59*1 40 7.44 28 2
Brief Hospital Course:
82 year old woman with history of CAD s/p MI in [**2117**], PCI to LM,
LAD, and RCA, angina, HTN, HL, PVD, AAA s/p repair, CEA, CKD (Cr
2.5), severe pulmonary hypertension, HIT, history of PE now off
warfarin, and oxygen-dependent COPD who presents with
progressive SOB and hypoxia.
.
# Hypoxia- Patient was admitted with marked hypoxia and
significant A-a gradient with PaO2 of 44 on a 50% venti mask.
Initially given her level of hypoxia and history of PE and
recent discontinuation of [**Year (4 digits) **], PE seemed a likely
explanation of her symptoms, espeically as her CXR was not felt
to be consistent with significant fluid overload and effusions
appeared stable. She was empirically started on argatroban
(given history of HIT). However, b/l LENIs were negative and
echo did not show any signs of new right heart strain (Echo w/
signs of RV volume and pressures overload and severe pulmonary
hypertension. However PA pressure not significantly changed from
prior). Upon further investigation it was determined patient had
recieved [**Year (4 digits) **] in the past for a questionable history of PE
based on an indeterminate VQ scan at [**Hospital1 112**]. Given her clinical
picture and the risk of bleed on triple anticoag (asa and plavix
in addition to [**Hospital1 **]) [**Hospital1 **] was d/c-ed during prior
hospitalization. Given the lack of definitive signs of PE as
above and the inability to definitively evaluate with contrast
CT chest, argatroban was d/ced. Non contrast CT was undertaken
on [**5-9**] after pulmonary was consulted to further illucidate
potential etiologies for hypoxia and showed "mild to moderate
centrilobular emphysema; bilateral pleural effusions left>right
with marked left lower lobe atelectasis; Peripheral opacity in
the right lower lobe, which may represent focal pneumonia or
aspiration, although an infarct is also considered possible in
the appropriate clinical setting; Ground-glass opacity
accompanied by mild interstitial thickening and fissural fluid
suggestive of pulmonary edema." It was thus felt that her
hypoxia was likely multifactorial with contribution from COPD,
VQ mismatch in the presence of large left effusion and
atelectasis, PHTN, possible mucous plugging as well as pulmonary
congestion. The pleural effusions were felt to be organized and
not candidates for drainage per both pulmonary and
interventional pulmonology. Patient was started on azythromycin,
inhaled steroids, mucolytics and bronchodilators. Sildenafil was
started empirically for PHTN with no significant improvement.
Given evidence of pulm congestion per CT IV Lasix was started on
[**5-10**] with balance of neg 1L after 24h and apparent improvement
in respiratory status, though oxygen requirement remained
similar (sats in low 90s on 5L NC, desated to 70s on RA). The
patient had a right heart cath on [**5-19**], which showed wedge of 13,
PVRs of 9 [**Doctor Last Name 6641**] units that improved to 8 [**Doctor Last Name 6641**] units with NO.
Pulmonary was asked whether they would recommend treating the
pulmonary hypertension. They suggested that sildenafil 20 mg TID
could be tried, but would be unlikely to offer significant
benefit. Pulmonary f/u was scheduled to address this issue as an
outpatient.
.
CCU Course #2 ([**5-13**] - [**2149-5-21**])
Transferred to the unit for respiratory distress. CXR showed
worsening left pleural effusion and stable pulmonary edema. TTE
showed worsenig right ventricular pressure/overload compard to
previous TTE. Interventional pulmonology was consulted and they
performed bedside thoracentesis with removal of 1200 cc of
pleural fluid. Stain showed no organism and fluid was
transudative in nature. Culture was negative. She was also
diuresed two liters with IV lasix with significant improvement
in her respiratory status. She was also started on [**Month/Day/Year **]
with concern for pulmonary embolism.
.
# CAD: Patient w/ significant h/o CAD s/p recent stenting to
LMCA and LAD [**2149-4-23**] and prior stenting to RCA/LAD in [**2140**]. Cath
on [**4-28**] showed patent stents. Patient with stable angina-
unchanged from prior admission. Slight troponin leak at OSH, but
likely secondary to underlying CKD. EKG appeared at baseline.
She was continued on her asa, plavix, metoprolol, statin,
amlodipine and imdur without any significant complaints of
angina during her hospitalization.
.
# Acute on Chronic Diastolic CHF: No history of systolic heart
failure per echo at [**Location (un) 2274**] in [**10-23**] (EF 50-55%). She did not
appear volume overloaded on exam, but did have stable pleural
effusions and evidence of pulmonary congestion per CT chest.
Cardiac echo shows preserved EF, but depressed RV free wall
contractility. Given evidence of pulm congestion per CT IV Lasix
was started on [**5-10**] with balance of neg 1L after 24h and
apparent improvement in respiratory status and slightly reduced
oxygen need. ON [**5-19**], RH cath was performed to investigate
whether pulmonary hypertension could respond to vasoactive
agents. This showed mild (17% drop in PVR) following
administration of NO. Discussed with pulm who felt pt could try
sildenafil, however given the interaction with imdur would be
concerning for hypotension, therefore pt will follow up with
pulm as an outpt, no new intervention at this time.
.
# RHYTHM: No history of conduction disease. Was monitored on
tele and remained in sinus w/ frequent PVCs.
.
# Chronic Kidney Disease: Baseline creatinine appears to be
2.5-2.7. She remained around her baseline during this
hospitalization. Medications were renally dosed and nephrotoxins
were avoided.
.
# Hypertension- Currently normotensive on home regimen.
Continued imdur, amlodipine.
.
# COPD- Per pulmonary may be having exacerbation given phlegm
despite normal exam. Non con CT chest was performed as above and
patient was started on azithromycin on [**5-8**] for planned 5d
course. Was also started on advair and standing nebs. Spiriva
was restarted on discharge.
.
CODE: DNR/DNI (CONFIRMED W/ PT)
Medications on Admission:
1. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for chest pain: repeat every 5 minutes
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. levalbuterol tartrate 45 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) puffs Inhalation every 4-6 hours as needed for
shortness of breath or wheezing.
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. multivitamin One (1) Tablet PO DAILY (Daily).
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
17. Oxygen 2 Liters at rest, 3 Liters with activity
Discharge Medications:
1. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Give up to three tablets for chest pain 5 minutes apart, hold
SBP< 90.
7. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q6hr () as needed for sob, wheezing.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Calcium Citrate + 315-200 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
14. ferrous sulfate 324 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
15. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold
SBP < 100.
16. furosemide 40 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
18. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: goal INR 1.8-2.2.
19. Outpatient Lab Work
Check chem-7, CBC and INR on Friday [**2149-5-23**]
20. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times
a day as needed for pain.
21. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
22. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for to loosen mucous.
23. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily):
Hold SBP < 90, HR < 55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1514**] Health Care Center - [**Location (un) 1514**]
Discharge Diagnosis:
Pulmonary hypertension
Pneumonia
Acute on Chronic Diastolic Congestive heart failure: holding ACE
because of increased creatinine
Coronary artery disease
Chronic obstructive pulmonary disease
Acute on chronic kidney disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had trouble breathing and a low oxygen level and was
admitted for treatment. We treated you for a pneumonia,
increased your diuretics to remove more fluid and removed the
fluid on the left side by draining it with a needle. Your
breathing improved considerably and your oxygen requirement is
now the same as when you were home. We performed a cardiac
catheterization to see if a medicine, Sildenifil, would help the
pressures in the vessels inside your lungs. The test showed that
there was mild improvment. Given the cost of this medicine and
difficulty getting the medicine at rehab, we have not started it
now but will defer to your pulmonologist, Dr. [**Last Name (STitle) **]. Right
now, your weight is 121 pounds and you should consider this your
ideal weight. Weigh yourself every morning, call Dr. [**Last Name (STitle) 2257**] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start miralax daily and senna as needed to avoid constipation
2. Start Advair to treat your COPD
3. Start calcium and vitamin d to prevent osteoporosis
4. Increase lasix to 100 mg daily to prevent fluid accumulation
in your lungs and abdomen
5. Decrease metoprolol to lower your heart rate
6. Stop amlodipine
7. Start warfarin 3mg daily to prevent a stroke. Your goal INR
is 1.8-2.2
8. Start tylenol for pain
9. Start robitussin cough syrup to help your cough
10. STart trazadone as needed for insomnia
Followup Instructions:
Name: [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 2564**], NP
Specialty: Cardiology
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Appointment: [**5-30**] at 11:50am
Name: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Pulmonology
[**Hospital1 **]
[**Location (un) 2129**] Pulmonary Dept 5th Fl
[**Location (un) 86**] [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 89288**]
When: [**6-12**] at 11:40
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2264**]
|
[
"413.9",
"403.90",
"496",
"511.9",
"414.00",
"416.9",
"V15.82",
"790.92",
"428.0",
"V49.86",
"585.9",
"584.9",
"486",
"518.0",
"428.33",
"V45.82",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.21",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
19691, 19783
|
9861, 15896
|
501, 527
|
20064, 20064
|
6124, 6124
|
21795, 22457
|
4567, 4662
|
17399, 19668
|
19804, 20043
|
15922, 17376
|
9401, 9595
|
20247, 21772
|
9611, 9838
|
4677, 4677
|
5619, 6105
|
454, 463
|
555, 3326
|
6138, 9384
|
20079, 20223
|
3718, 4328
|
4344, 4551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,338
| 149,473
|
7499
|
Discharge summary
|
report
|
Admission Date: [**2127-2-4**] Discharge Date: [**2127-2-9**]
Date of Birth: [**2077-7-1**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
The patient presents for a living related renal transplant for
ESRD.
Major Surgical or Invasive Procedure:
Living related kidney transplant.
History of Present Illness:
The patient is a 49-year-old male with type 1 diabetes, who is
12 years out from a living related kidney transplant that has
gradually deteriorated over the past decade. He underwent a
pancreas-after-kidney transplant in [**2122**] that was complicated by
a ventral hernia that required repair with a mesh. He has a
brother, who does want to serve as a donor, and he presents for
donation. [**Known firstname **] has completed his workup and has no
contraindications to proceeding with the transplantation.
Reportedly, the kidney is on the right side and the pancreas is
on the left. We would likely proceed with the placement of the
kidney on the right side via probably an intra-abdominal
approach. His pre-transplant workup includes a colonoscopy in
[**2126-12-26**] that was unremarkable. A [**Year (4 digits) **] echo
demonstrated no evidence of ischemia. Cardiac echo showed normal
left ventricular function.
Past Medical History:
1)s/p renal transplant [**2113**](LRRT13 years ago from his sister),
c/b necrotizing fasciitis
2)Pancreas after kidney transplant [**2123**]
3)DVT X3, hx PE, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter
4)Type I DM since [**2090**], wtih triopathys/p ventral hernia repair
5) open cholecystectomy [**2123**]
6) EF 60%
7) hx CVA of basal ganglia on heparin
8) HTN
Social History:
married to 4th wife, lives in [**Name (NI) 6134**]
no tob,no etoh no illicit drug use
Family History:
FH: mother with PE, father died from post-op PE in 70s, multiple
family members on father's side with Type II DM
Physical Exam:
VITAL SIGNS: His blood pressure is 146/70, pulse 80,
respirations 20, temperature is 98.8, and weight is 195 pounds.
ABDOMEN: Soft, nontender, and nondistended. He has a right
iliac fossa incision and a palpable kidney, midline incision
with
a large ventral hernia defect repaired with a Marlex.
EXTREMITIES: His femorals are 2+ and equal bilaterally. He has
no peripheral edema. He is mildly obese.
Pertinent Results:
[**2127-2-4**] 11:43AM GLUCOSE-100 UREA N-47* CREAT-5.3*# SODIUM-142
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
[**2127-2-4**] 11:43AM PHOSPHATE-8.9*# MAGNESIUM-1.5*
[**2127-2-4**] 11:43AM WBC-3.1*# RBC-4.59* HGB-12.8* HCT-40.3 MCV-88
MCH-27.9 MCHC-31.9 RDW-18.4*
[**2127-2-4**] 11:43AM PLT COUNT-192
[**2127-2-4**] 10:06AM TYPE-ART RATES-/10 TIDAL VOL-700 O2-50 PO2-90
PCO2-44 PH-7.35 TOTAL CO2-25 BASE XS--1 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2127-2-4**] 10:06AM GLUCOSE-106* LACTATE-1.1 NA+-141 K+-3.8
CL--102
[**2127-2-4**] 10:06AM HGB-13.0* calcHCT-39
[**2127-2-4**] 10:06AM freeCa-1.05*
[**2127-2-9**] 05:45AM BLOOD FK506-9.3
[**2127-2-7**] 03:44AM BLOOD Glucose-101 UreaN-31* Creat-1.8* Na-137
K-4.1 Cl-107 HCO3-24 AnGap-10
[**2127-2-7**] 03:44AM BLOOD WBC-5.0 RBC-3.82* Hgb-11.2* Hct-33.9*
MCV-89 MCH-29.2 MCHC-32.9 RDW-18.8* Plt Ct-142*
[**2127-2-9**] 05:45AM BLOOD WBC-3.8* RBC-3.85* Hgb-11.1* Hct-34.3*
MCV-89 MCH-28.9 MCHC-32.4 RDW-18.5* Plt Ct-170
[**2127-2-9**] 05:45AM BLOOD Plt Ct-170
[**2127-2-9**] 05:45AM BLOOD PT-14.5* PTT-150* INR(PT)-1.4
[**2127-2-9**] 05:45AM BLOOD Fibrino-387
[**2127-2-9**] 05:45AM BLOOD Glucose-83 UreaN-11 Creat-1.4* Na-140
K-4.2 Cl-110* HCO3-20* AnGap-14
[**2127-2-9**] 05:45AM BLOOD ALT-87* AST-23 LD(LDH)-275* AlkPhos-287*
Amylase-26 TotBili-0.9
[**2127-2-9**] 05:45AM BLOOD Albumin-3.1* Calcium-10.9* Phos-1.4*
Mg-2.2
Brief Hospital Course:
The patient tolerated the procedure well. He was immediately
placed on the kidney transplant medication protocal. He did
well post-operatively, producing 300-400cc/hr of urine
throughout his hospital stay. On [**2127-2-4**], the patient's BUN was
47 and his creatinine was 5.3. On [**2127-2-9**], the patient's BUN
was 11, and his creatinine was 1.4. The [**Hospital 228**] hospital
course was complicated on post-op day 2 by fevers, chills, and
oxygen desaturation on room air. He was immediately
transferred to the surgical intensive care unit, where he stayed
for two days. He was emperically treated with Vancomycin and
Zosyn. He responded well to the antibiotics, and was
subsequently transferred back to the transplant floor were re
remained until day of discharge. On day of discharge, he had
been ambulating, tolerating a regular diet, producing flatus and
adequate urine, while having minimal pain. He was discharged in
good condition which very throrough and specific intructions for
medications and follow-up.
Medications on Admission:
atorvastatin 20 mg po daily
prednisone 2.5 mg po daily
rapamne 4 mg po daily
prograf 1 mg po bid
protonix 40 mg po daily
neprocap
carvedilol 12.5 mg po daily
FeSO4
renagel
Coumadin 2 mg po daily
Bactrim SS 1 po daily
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet PO DAILY
(Daily).
2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
6. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H
10. Tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO twice a day
11. Insulin sliding scale
Discharge Disposition:
Home
Discharge Diagnosis:
End stage renal disease.
Diabetes mellitus.
Discharge Condition:
Good
Discharge Instructions:
Please follow directions as discussed previously by Dr.
[**First Name (STitle) **]/Transplant Coordinator.
Please take medications as prescribed and read warning labels
carefully. If signs of infections such as fever greater than
101.4 F, purulent discharge from wound, increased pain and
redness at wound site, please call or go to the emergency room.
If you experience difficulty urinating, pain with urination,
icreased pain at transplanted kidney site, please call or go to
the emergency room. Remember to call for a follow up
appointment (bellow) and have lab checks twice a week or
directed by attending surgeon/transplant coordinator. Light
activities until seen in clinic. [**Month (only) 116**] sponge bathe or take
shower if shower hose can be directed to minimize getting wound
and drains wet. No baths. If you still have staples, they will
be addressed during your follow up visit. If you have
steri-strips, do not peel them off--it may take off the scab.
Trim the edges if necessary. Otherwise, they will fall off on
their own after about a week. Absolutely no smoking because
tobacco will slow/inhibit wound healing.
Remember to go and check your blood twice a week, as discussed
by the Transplant Coordinator.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2127-2-14**] 10:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2127-2-20**] 2:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2127-2-27**] 2:30
Completed by:[**2127-2-12**]
|
[
"250.51",
"250.61",
"250.41",
"403.91",
"V42.83",
"357.2",
"585.6",
"486",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.91",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
5874, 5880
|
3839, 4870
|
351, 387
|
5968, 5975
|
2419, 3816
|
7260, 7745
|
1869, 1983
|
5138, 5851
|
5901, 5947
|
4896, 5115
|
5999, 7237
|
1998, 2400
|
242, 313
|
415, 1333
|
1355, 1749
|
1765, 1853
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
124
| 112,906
|
2575
|
Discharge summary
|
report
|
Admission Date: [**2161-12-17**] Discharge Date: [**2161-12-24**]
Date of Birth: [**2090-11-19**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Descending thoracic aortic
pseudoaneurysm.
HISTORY OF PRESENT ILLNESS: This is a 71-year-old gentleman
with a history of peripheral vascular disease and COPD with
hypertension and coronary artery disease, who presented to
the Emergency Department with 10 days of cough, shortness of
breath, and chest pain. Patient had been seen earlier in the
week and started on Zithromax for presumed respiratory
infection. However, he returned on the day prior to
admission with recurrent cough. CTA done at that time showed
a partially thrombosed pseudoaneurysm or penetrating ulcer of
the aortic arch approximately 2.5 cm distal to the takeoff of
the left subclavian artery with diffuse emphysematous
changes, no pulmonary embolus.
He was started on esmolol for blood pressure control, given
an elevated pressure of 175/48 when he was admitted. He had
appropriate monitoring placed including an A line and a Foley
catheter, and admission laboratories were significant for a
hematocrit of 41.4 and a BUN and creatinine of 26 and 1.4.
His EKG did not show ischemic changes and his CK's and
troponins were negative initially. Vascular Surgery and
Cardiothoracic Surgery services were consulted and he was
admitted to the Intensive Care Unit on the Vascular Surgery
service.
PAST MEDICAL HISTORY: Right cerebrovascular accident.
Coronary artery disease.
Hypertension.
Prostate cancer.
History of hepatitis C.
Hypercholesterolemia.
Hypertension.
Asthma.
PAST SURGICAL HISTORY: Left carotid endarterectomy in [**2161-8-16**].
Right carotid endarterectomy in [**2161-6-16**].
Five vessel CABG in [**2152**].
Right upper lobectomy for lung cancer in [**2154**].
Left vertebral artery stent in [**2161-6-16**].
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Albuterol.
2. [**Doctor First Name **].
3. Lipitor 20 mg by mouth every day.
4. Cartia XT 300 mg by mouth every day.
5. Ecotrin 325 mg by mouth every day.
6. Hydrochlorothiazide 25 mg by mouth every day.
7. Protonix 40 mg by mouth every day.
8. Serevent every day.
SOCIAL HISTORY: The patient is a former smoker. He quit in
[**2160-5-15**] with a greater than 30 pack year history. Denies
ingestion of alcohol.
INITIAL PHYSICAL EXAMINATION: Temperature 96.9, heart rate
64, blood pressure initially 131/73 down to 110/57 after
institution of esmolol, 93 percent. He was alert and in no
acute distress. His heart was regular with no murmurs, rubs,
or gallops. His chest was clear to auscultation with
diminished breath sounds in the bases. His abdomen was
moderately obese with normoactive bowel sounds, soft, and
nontender. Extremities were warm without clubbing, cyanosis,
or edema. He had palpable femoral pulses bilaterally and
Dopplerable popliteal, DP and PT bilaterally with monophasic
DP and PT on the left.
STUDIES: CTA: No pulmonary embolus. A 3 cm partially
thrombosed pseudoaneurysm versus penetrating ulcer of aortic
arch 2.5 cm distal to the takeoff of the left subclavian
artery, diffuse emphysematous changes.
Chest x-ray: No new infiltrate.
BRIEF HOSPITAL COURSE: As stated above, Mr. [**Known lastname 13029**] was
admitted to the ICU for blood pressure control on an esmolol
drip. He remained without recurrent chest pain and he had a
MRI/MRA done of his chest to further delineate his anatomy.
Of note, there were two small outpouchings of contrast from
the lumen of the inferior portion of the aortic arch
surrounded by large thrombus component with some thickening
of the aortic wall and no evidence of active bleeding or free
fluid. There were additionally multiple irregularities in
the aortic wall throughout the entire thoracic and abdominal
aorta that was visualized. This was thought to represent an
unusual appearance of a penetrating ulcer with a large
thrombus component.
He additionally had a cardiac catheterization to evaluate for
any underlying coronary artery disease should he need
operative repair. This revealed 90 percent stenosis of his
right coronary artery, saphenous vein graft with patent vein
grafts to the OM and patent LIMA to the LAD with diffuse
disease in the distal LAD. A Heparin-coated stent was placed
in the vein graft to the right coronary artery.
Other findings from his catheterization revealed an 80
percent instent stenosis of the left vertebral artery and an
80 percent right brachiocephalic ostial lesion. He tolerated
the procedure well and there were no bleeding or groin
complications. He returned to the Intensive Care Unit for
continued blood pressure monitoring and his esmolol drip was
eventually weaned off.
Given the patient's multiple medical problems including his
severe pulmonary disease, underlying coronary artery disease,
and overall debilitated condition, the decision was made to
proceed with medical management as the postoperative
management of this likely penetrating ulcer. He was
transitioned to oral agents. His diltiazem dose was
increased and Lopressor was added for additional rate
control. He remained off drips for greater than 48 hours.
Decision was made to send him home with close followup. Of
note, his hematocrit remained stable. His creatinine
remained within its baseline of around 1.4 and he was
tolerating a regular diet and able to ambulate without
difficulty.
Of note, because of his complaint of cough, a sputum sample
was sent, which grew out Pseudomonas that was [**Last Name (LF) 7384**],
[**First Name3 (LF) **] he was started on ciprofloxacin on [**2161-12-22**].
Follow-up chest x-ray revealed bilateral lower lobe changes
concerning for pneumonia. He remained afebrile with normal
white count.
DISCHARGE DIAGNOSES: Penetrating ulcer versus thrombosed
pseudoaneurysm of the descending thoracic aorta.
Coronary artery disease status post right coronary artery
saphenous vein graft stent with Heparin-coated stent.
Bilateral lower lobe pneumonia.
DISCHARGE MEDICATIONS:
1. Salmeterol.
2. Flovent.
3. Lipitor 20 mg by mouth every day.
4. Tylenol as needed.
5. Aspirin 325 mg by mouth every day.
6. Hydrochlorothiazide 50 mg by mouth every day.
7. Diltiazem sustained release 360 mg by mouth every day.
8. Lopressor 12.5 mg by mouth twice a day.
9. Ciprofloxacin 500 mg by mouth every 12 hours times seven
days additional.
DISCHARGE INSTRUCTIONS: Patient is to have his blood
pressure checked 3-4 times per week and communicate these
results with Dr. [**Last Name (STitle) **] and his primary care doctor. He
should call if his systolic blood pressure is greater than
110 or less than 90. Complete a 10 day course of
ciprofloxacin to take seven additional days and to call Dr.
[**Last Name (STitle) **] should he have recurrent chest discomfort. Follow
up with Dr. [**Last Name (STitle) **] in one month with a CTA of his chest,
with Dr. [**First Name4 (NamePattern1) 1169**] [**Last Name (NamePattern1) **], his primary care doctor in two
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 13030**]
MEDQUIST36
D: [**2161-12-24**] 10:45:31
T: [**2161-12-24**] 11:59:21
Job#: [**Job Number 13031**]
|
[
"070.70",
"441.2",
"486",
"496",
"414.02",
"401.9",
"447.8",
"414.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.06",
"88.56",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
3249, 5791
|
5813, 6045
|
6068, 6424
|
6449, 7323
|
1659, 2215
|
2396, 3225
|
179, 223
|
252, 1448
|
1471, 1635
|
2232, 2373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,821
| 170,329
|
1587
|
Discharge summary
|
report
|
Admission Date: [**2133-4-20**] Discharge Date: [**2133-5-15**]
Date of Birth: [**2096-9-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 9223**]
Chief Complaint:
Sudden onset HA and neck pain radiating to L sided temporal and
neck pain.
Major Surgical or Invasive Procedure:
Coil embolization of a ruptured distal right PICA aneurysm
History of Present Illness:
36 yo HIV+ M in his usual state of health until the AM of [**4-17**]
when he developed a severe L-sided HA with radiation to his neck
and temporal area associated with photophobia. He denies
however, N/V, CP, SOB or anticedent trauma.
Past Medical History:
1. Enuresis seen by Sleep Clinic.
2. Alcohol abuse; no alcohol for 12 years.
3. Human immunodeficiency virus diagnosed in [**2122**]. History
of pneumocystis carinii pneumonia. Has been on HAART, now
off since [**10/2131**] due to insurance reasons. Viral load last
undetectable in 11/[**2130**].
Social History:
Patient is a gay male, runs a restaurant, is a current 2 ppd
smoker for many
years. Prior alcohol and cocaine 11 years ago.
Family History:
Lives alone. + for CAD, but neg for prior know CVD.
Physical Exam:
96.5 134/70 68 16 100%RA
NAD
CTA-B/RRR
EXT: smooth, symmetric, purposeful motion of all 4 ext,
sensation intact no edema
ABD NT/ND
NEURO: AOx3, NEG pronator drift. CNII-XII intact B, EOMI,
PERRLA
Pertinent Results:
[**2133-4-20**] 06:00AM BLOOD WBC-9.0# RBC-4.84 Hgb-13.9* Hct-39.5*
MCV-82 MCH-28.7 MCHC-35.2* RDW-14.0 Plt Ct-183
[**2133-4-20**] 05:18PM BLOOD WBC-7.3 RBC-4.10* Hgb-12.0* Hct-33.7*
MCV-82 MCH-29.1 MCHC-35.4* RDW-14.1 Plt Ct-172
[**2133-4-21**] 03:15AM BLOOD WBC-9.6 RBC-4.15* Hgb-11.8* Hct-33.8*
MCV-81* MCH-28.4 MCHC-34.9 RDW-14.2 Plt Ct-175
[**2133-5-1**] 03:30AM BLOOD WBC-3.9* RBC-4.02* Hgb-11.7* Hct-32.6*
MCV-81* MCH-29.0 MCHC-35.8* RDW-14.5 Plt Ct-206
[**2133-5-13**] 03:12AM BLOOD WBC-5.5 RBC-3.55* Hgb-10.3* Hct-31.4*
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.7* Plt Ct-439
[**2133-5-14**] 06:25AM BLOOD WBC-5.3 RBC-3.64* Hgb-10.1* Hct-31.8*
MCV-87 MCH-27.9 MCHC-31.9 RDW-15.5 Plt Ct-396
[**2133-4-20**] 06:00AM BLOOD PT-12.1 PTT-23.9 INR(PT)-1.0
[**2133-4-20**] 06:00AM BLOOD Plt Ct-183
[**2133-4-20**] 05:18PM BLOOD PT-13.4* PTT-79.9* INR(PT)-1.2
[**2133-4-20**] 05:18PM BLOOD Plt Ct-172
[**2133-4-21**] 03:15AM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1
[**2133-4-21**] 03:15AM BLOOD Plt Ct-175
[**2133-5-7**] 02:47AM BLOOD PT-11.2* PTT-26.3 INR(PT)-0.8
[**2133-5-7**] 02:47AM BLOOD Plt Ct-440
[**2133-5-13**] 03:12AM BLOOD PT-11.2* PTT-20.7* INR(PT)-0.8
[**2133-5-13**] 03:12AM BLOOD Plt Ct-439
[**2133-4-20**] 06:00AM BLOOD WBC-9.0 Lymph-29 Abs [**Last Name (un) **]-2610 CD3%-88
Abs CD3-2303* CD4%-11 Abs CD4-284* CD8%-75 Abs CD8-[**2082**]*
CD4/CD8-0.2*
[**2133-4-21**] 02:00PM BLOOD WBC-9.6 Lymph-19 Abs [**Last Name (un) **]-1824 CD3%-86
Abs CD3-1569 CD4%-14 Abs CD4-249* CD8%-70 Abs CD8-1285*
CD4/CD8-0.2*
[**2133-4-20**] 06:00AM BLOOD Glucose-169* UreaN-14 Creat-0.9 Na-136
K-3.6 Cl-102 HCO3-23 AnGap-15
[**2133-4-21**] 03:15AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-137
K-4.1 Cl-105 HCO3-22 AnGap-14
[**2133-4-21**] 02:00PM BLOOD Glucose-123* UreaN-8 Creat-0.6 Na-137
K-4.2 Cl-108 HCO3-22 AnGap-11
[**2133-4-29**] 03:55AM BLOOD Glucose-106* UreaN-10 Creat-0.5 Na-129*
K-4.1 Cl-99 HCO3-20* AnGap-14
[**2133-4-30**] 03:46AM BLOOD Glucose-117* UreaN-10 Creat-0.5 Na-132*
K-4.2 Cl-101 HCO3-20* AnGap-15
[**2133-5-1**] 03:30AM BLOOD Glucose-107* UreaN-9 Creat-0.5 Na-132*
K-4.0 Cl-101 HCO3-23 AnGap-12
[**2133-5-2**] 04:05AM BLOOD Glucose-200* UreaN-9 Creat-0.5 Na-137
K-3.6 Cl-103 HCO3-24 AnGap-14
[**2133-5-3**] 03:29AM BLOOD Glucose-138* UreaN-9 Creat-0.4* Na-142
K-3.3 Cl-106 HCO3-25 AnGap-14
[**2133-5-3**] 11:24AM BLOOD Glucose-248* UreaN-11 Creat-0.4* Na-141
K-3.3 Cl-105 HCO3-25 AnGap-14
[**2133-5-5**] 03:47AM BLOOD Glucose-148* UreaN-14 Creat-0.5 Na-142
K-3.7 Cl-105 HCO3-27 AnGap-14
[**2133-5-6**] 02:07AM BLOOD Glucose-123* UreaN-16 Creat-0.6 Na-143
K-3.8 Cl-106 HCO3-28 AnGap-13
[**2133-5-13**] 03:12AM BLOOD Glucose-98 UreaN-16 Creat-0.5 Na-143
K-3.9 Cl-105 HCO3-29 AnGap-13
[**2133-5-14**] 06:25AM BLOOD Glucose-106* UreaN-10 Creat-0.5 Na-143
K-4.2 Cl-107 HCO3-28 AnGap-12
[**2133-4-20**] 06:00AM BLOOD ALT-26 AST-32 AlkPhos-71 Amylase-40
TotBili-0.3
[**2133-5-9**] 06:00AM BLOOD ALT-107* AST-26
[**2133-4-20**] 05:18PM BLOOD Calcium-7.3* Phos-3.6 Mg-1.5*
[**2133-4-21**] 02:00PM BLOOD Calcium-7.5* Phos-2.2* Mg-2.1
[**2133-4-21**] 10:23PM BLOOD Calcium-8.3* Phos-1.8* Mg-2.2
[**2133-5-9**] 03:36AM BLOOD Calcium-6.4* Phos-2.8 Mg-1.4*
[**2133-5-13**] 03:12AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.0
IMAGING:
CT ([**4-19**]): Diffuse subarachnoid hemorrhage seen predominantly
in the
sylvian fissures, tentorium, third ventricle, and in the
proximal cervical
spine surrounding the cord. CT angiogram is recommended for
further
evaluation of this finding, or a conventional angiogram, to rule
out a
ruptured aneurysm.
ANGIO ([**4-20**]): Successful coil embolization of a ruptured distal
right PICA 3 [**12-7**] x 3 x 2.8 mm aneurysm with GDC
three-dimensional and Ultrasoft coils.
CT ([**4-21**]): A ventricular drainage catheter is again
seen. There is interval reduction in size of the ventricular
system, which is now fairly slit-like. There is a small amount
of blood seen within the third and fourth ventricles. No other
specific interval changes are seen.
CONCLUSION: Status post coiling of right posterior-inferior
cerebellar artery aneurysm with other findings as noted above.
CTA ([**4-28**]): No clear evidence of vasospasm or new infarction.
There is a small amount of hemorrhage seen along the catheter
tract which appears new compared to the prior study. Layering
hemorrhage seen within the occipital horns of both lateral
ventricles is slightly decreased from the prior study.
CXR ([**4-30**]): IMPRESSION: Faint opacity at the right lung base,
which appears improved in
comparison to the prior study, and likely represents improving
pneumonia.
LENIs ([**5-8**]): NEG for DVT
CTA/CT ([**5-9**]):
1) Status post removal of right ventricular drainage catheter.
No evidence
of hydrocephalus. Resolution of previously seen intraventricular
blood
products.
2) Unchanged appearance of the cerebral vasculature in
comparison with CTA
dated [**2133-4-27**].
Brief Hospital Course:
Patient was admitted to the ICU s/p subarchnoid hemorrhage with
hydrocephalus. He had a ventricular drain placed on [**4-20**]. He was
taken to Angio on [**4-20**] which showed a right PICA aneurysm which
was coiled successfully. The Patient was then monitored in the
ICU for vasospasm. He had difficulties with hyponatremia
requiring 3% saline and high dose hydrocortisone. He remained in
the ICU until [**5-12**] when he was transfered to the step down unit.
He remained neurologically intact throughout his ICU stay. He
was in step down unit for two days then transfered to the
regular floor. He was cleared for discharge home by physical
therapy and was discharged on [**5-15**] in stable condition with
followup with Dr [**Last Name (STitle) 1132**] in two weeks.
Medications on Admission:
Atevol
Celexa
(off HAART)
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Phenytoin 100 mg/4 mL Suspension Sig: Ten (10) ml PO three
times a day for 3 weeks.
Disp:*qs 630 ml* Refills:*2*
4. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*15 Tablet(s)* Refills:*0*
5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Didanosine 250 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*
7. Efavirenz 200 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*14 Patch 24HR(s)* Refills:*0*
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
10. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Subarachnoid hemorrage
2) Hydrocephalus
3) PICA aneurysm
Discharge Condition:
Good, improving
Discharge Instructions:
Discharge to home with instructions to follow up as stipulated
below. If you experience severe HA, visual disturbances,
nausea/vomitting, dyscoordination or other symptoms concerning
to you, please seek medical evaluation at a convenient ED.
You may resume your regular diet.
You may resume your home medications with the below additions.
You should avoid moderate to strenuous at least until your
follow up visit with Dr. [**Last Name (STitle) 1132**].
Followup Instructions:
Please call Dr.[**Name (NI) 9224**] office to schedule a follow-up
appointment:
([**Telephone/Fax (1) 88**] LMOB 3B Neurosurgery
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 9225**]
Completed by:[**2133-5-15**]
|
[
"V11.3",
"331.4",
"401.9",
"486",
"430",
"253.6",
"042",
"V17.3",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"03.31",
"88.41",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
8478, 8484
|
6382, 7152
|
361, 422
|
8588, 8605
|
1467, 6359
|
9108, 9376
|
1172, 1226
|
7228, 8455
|
8505, 8567
|
7178, 7205
|
8629, 9085
|
1241, 1448
|
247, 323
|
450, 687
|
709, 1014
|
1030, 1156
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,246
| 150,542
|
2748+55403
|
Discharge summary
|
report+addendum
|
Admission Date: [**2126-7-17**] Discharge Date:
Date of Birth: [**2067-10-24**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: A 58-year-old female with a past
medical history of severe coronary artery disease complicated
by myocardial infarction, status post stenting, coronary
artery bypass graft times two, atrial fibrillation/atrial
flutter, status post ablation and cardioversion, pacemaker
placement, congestive heart failure with an ejection fraction
of less than 20%, hypertension, type 2 diabetes,
hypercholesterolemia, and mitral valve replacement, who
presented to [**Hospital3 1280**] Hospital status post a fall secondary
to instability. The patient was found to be hypotensive with
a systolic blood pressure in the 70s to 80s. This was
complicated by acute renal failure and an elevated digoxin
level. In addition, the patient also had a low hematocrit in
the setting of an elevated INR.
The patient had a similar episode on her last admission to
[**Hospital1 69**] on [**2126-6-5**];
admitted with hypotension and an elevated INR for which she
received dopamine and fresh frozen plasma/vitamin K with good
result. She has had increasing edema and ascites since this
last admission that has been resistant to outpatient diuretic
treatment. The patient has gained about 30 pounds since last
admission. For the two months prior to admission, the patient
has been experiencing worsening leg weakness.
On the a.m. of admission the patient began experiencing
lightheadedness. On the afternoon of admission the patient
was walking in her house and began losing her balance
secondary to leg weakness, per patient. She fell without
loss of consciousness. She denied headache, fever, chills,
sweats, dizziness, "blacking out," change in vision or chest
pain, shortness of breath, nausea, vomiting, palpitations,
incontinence, and diaphoresis at the time of the fall. The
fall was complicated by a 1-inch laceration on the back of
her head. She was able to crawl to a cell phone and call a
girlfriend who called an ambulance.
The patient arrive via ambulance to [**Hospital3 1280**] Hospital where
she received 1 unit of fresh frozen plasma, 1 liter of normal
saline, and dopamine at 8 mcg per minute, as well as suturing
of the laceration prior to her transfer to [**Hospital1 346**].
At [**Hospital1 69**], the patient still
denied headache, fevers, chills, sweats, dizziness, change in
vision, chest pain, shortness of breath, nausea, vomiting,
palpitations, and diaphoresis. At baseline, the patient
denies chest pain or palpitations. She does complain of
three-pillow orthopnea, paroxysmal nocturnal dyspnea, and
lower extremity edema.
PAST MEDICAL HISTORY:
1. The patient had a myocardial infarction in [**2120**]
resulting in a left bundle-branch block, also complicated by
ventricular tachycardia requiring lidocaine, and atrial
fibrillation requiring cardioversion.
2. The patient is status post catheterization, post
myocardial infarction in [**2120**]. Her proximal left circumflex
and distal right coronary artery were stented.
3. Status post coronary artery bypass graft in [**2120**]. Left
internal mammary artery to left anterior descending artery,
saphenous vein graft to first obtuse marginal, saphenous vein
graft to posterior descending artery, as well as a mitral
valve ring placed.
4. The patient is status post catheterization in [**2123**].
Catheterization showed occlusion of left internal mammary
artery and both saphenous vein grafts, severe systolic and
diastolic dysfunction bilaterally, moderate pulmonary
hypertension, and moderate-to-severe mitral regurgitation.
5. The patient had a coronary artery bypass graft redo
in [**2123**]; saphenous vein graft to left anterior descending
artery, saphenous vein graft to first diagonal to first
obtuse marginal, as well as mechanical mitral valve
replacement.
6. Pacemaker placement in [**2123**]; pacemaker is a DDD-type
with dual chamber leads.
7. The patient has a history of atrial flutter, status post
ablation and cardioversion in [**2124-11-18**]; and a history
of atrial fibrillation status post cardioversion in [**2125-4-19**].
8. The patient had a MIBI stress test done in [**2125-11-19**] which showed severe fixed inferolateral wall
defects.
9. The patient had an echocardiogram done in [**2125-1-17**]
which showed dilated left ventricle, global hypokinesis,
right ventricular akinesis, significant mitral regurgitation
and tricuspid regurgitation, mild pulmonary hypertension, and
an ejection fraction of less than 20%.
10. Hypertension.
11. Congestive heart failure.
12. Type 2 diabetes controlled with diet, not requiring
insulin.
13. Hypercholesterolemia.
14. Peripheral vascular disease with claudication. The
patient requires heart catheterization via brachial artery
due to severe peripheral vascular disease.
15. Depression.
16. Dysfunctional uterine bleeding with thickening
endometrium on ultrasound. This was found in [**2125-11-19**].
17. Obesity.
18. Anal fissure.
19. Questionable history of a gastrointestinal bleed that
has not been worked up.
FAMILY HISTORY: Family history is negative for coronary
artery disease.
SOCIAL HISTORY: The patient has a 70-pack-year history of
tobacco use; currently 5 to 10 cigarettes per day. No
alcohol use. No drug use. The patient lives with her
husband.
ALLERGIES: The patient has an allergy to CECLOR which gives
her hives.
MEDICATIONS ON ADMISSION: The patient's medications on
admission were gemfibrozil 600 mg p.o. b.i.d., [**First Name5 (NamePattern1) 233**]
[**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d., digoxin 0.125 mg p.o. q.d. (Monday
through [**Last Name (NamePattern1) 2974**]), Coumadin 2.5 mg p.o. q.d., Lasix 40 mg p.o.
b.i.d., Ativan 1 mg p.o. p.r.n. for insomnia, trazodone 50 mg
p.o. q.d., Zoloft 100 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
Coreg 3.125 mg p.o. b.i.d., Imodium 1 tablet q.6h. p.r.n. for
diarrhea, albuterol inhaler p.r.n., aldactazide 25/25 mg p.o.
b.i.d., atenolol 25 mg p.o. q.d., Lipitor 10 mg p.o. q.d.,
enalapril 2.5 mg p.o. b.i.d., and sublingual nitroglycerin.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed
pulse, the patient is AV paced at 70, blood pressure 91/25,
respiratory rate 14, oxygen saturation 98% on 6 liters. In
general, the patient was awake and verbal with unlabored
breathing, in no apparent distress. Skin examination
revealed ecchymosis on right forearm and right shoulder.
HEENT revealed extraocular movements were intact. Pupils
were equal, round, and reactive to light and accommodation.
The oropharynx was clear, moist oral mucosa. Stitches to the
back of her head of about one inch in length. Neck had no
lymphadenopathy, supple, no tenderness. Cardiovascular
examination revealed carotids with normal upstroke but low
volume. No bruits heard. JV engorged. Precordium with a
right ventricular heave and displaced point of maximal
impulse to midclavicular line and superiorly. The patient
had a regular rate, mechanical S1, loud S2, a [**12-25**] to [**1-22**]
early systolic murmur radiating to the axilla and clavicles.
No S3 or S4 heard. Lung examination revealed the patient had
crackles one-third of the way up on the right side and
crackles halfway up on her left side. There was good air
movement, and slight wheezing throughout. Abdominal
examination had positive bowel sounds, tense ascites,
distended, and nontender. Extremities had 3+ pitting edema
to middle thigh, right shoulder bruising and tenderness.
Neurologic examination revealed the patient was alert and
oriented. Cranial nerves II through XII were intact.
Strength was [**3-23**] throughout. Examination was nonfocal.
LABORATORY DATA ON ADMISSION: White blood cell count 10.3,
hematocrit 25.4, platelets 275. Sodium 132, potassium 5.1,
chloride 97, bicarbonate 21, BUN 48, creatinine 3.4,
glucose 65. PT 29.5, PTT 55.3, INR 5.7 (samples grossly
hemolyzed). Pertinent laboratory results revealed
Helicobacter pylori was negative. Urine cultures performed
on [**7-25**] showed greater than 100,000 Escherichia coli.
Peritoneal fluid, Gram stain, and culture performed on
[**7-19**] showed no growth and no organisms. Blood cultures
times two performed on [**7-19**] showed no growth.
RADIOLOGY/IMAGING: Electrocardiogram #1 performed on
[**7-18**] revealed the patient was AV paced at 70 with
diffuse low voltage.
Electrocardiogram #2 performed on [**7-22**] revealed the
patient was AV paced with no changes.
Echocardiogram #1 performed on [**7-19**] showed mildly
dilated left atrium. No atrial septal defect or patent
foramen ovale. Severe left ventricular global hypokinesis
with thinning/scar of left ventricular inferior wall. Apex
and septal dyskinesis. Remaining left ventricle severely
hypokinetic. Right ventricular dilation. Hypokinesis of
right ventricular free wall. No VSD. Trace aortic
insufficiency. Mitral regurgitation, 4+ tricuspid
regurgitation. Mild pulmonary hypertension. No effusion
seen.
Stress test performed in [**2125-11-19**] on [**Doctor Last Name 4001**] protocol,
total time 3.37 minutes with 46% of maximum heart rate
achieved. Stopped because of dizziness and shortness of
breath. No angina. MIBI showed severe fixed defects in
inferolateral walls.
Abdominal ultrasound performed on [**7-19**] showed ascites;
performed for paracentesis guidance.
Abdominal CT performed on [**7-19**] showed small-to-moderate
bilateral pleural effusions, cardiomegaly, gallstones,
ascites, inferior vena cava distention consistent with heart
failure; otherwise unremarkable.
A pelvic CT was performed on [**7-19**] which showed a large
amount of fluid and anasarca.
An esophagogastroduodenoscopy was performed on [**7-30**]
showing hiatal hernia without signs of upper gastrointestinal
bleed.
A colonoscopy was performed on [**8-5**] showing
proctitis.
Biopsy results: Rectal biopsy showed no abnormalities. The
biopsy was performed on [**8-5**].
IMPRESSION: This is a 58-year-old female with significant
cardiac history who presents with biventricular systolic
dysfunction right greater than left, likely secondary to
ischemic heart disease requiring dopamine for hypotension.
HOSPITAL COURSE:
1. CARDIOVASCULAR: (a) PUMP: The patient has
biventricular systolic dysfunction with an ejection fraction
of less than 20% presumed secondary to ischemic heart
disease. The patient failed outpatient diuresis with a
30-pound weight gain over approximately one month. On
admission, the patient presented with decompensated heart
failure requiring dopamine. Outpatient ACE inhibitor, beta
blocker, and diuretics were held.
A Swan-Ganz catheter was placed on hospital day two once INR
was less than 2 with the following findings: Central venous
pressure of 30, pulmonary artery pressure of 66/28/41,
pulmonary capillary wedge pressure of 40, cardiac
output/cardiac index of 8.8/4.1, systemic vascular resistance
of 282. Elevated central venous pressure likely secondary to
right heart failure and 4+ tricuspid regurgitation.
Intra-cardiac shunt was ruled out via echocardiogram. Low
systemic vascular resistance thought to be due to either
sepsis or chronic outpatient use of beta blocker and ACE
inhibitors. Sepsis workup was negative. Hypothyroidism and
Addison disease were ruled out. Initially,
dopamine/dobutamine were started on hospital day two with a
poor renal response. Dobutamine was then discontinued, and
Neo-Synephrine/dopamine was started on hospital day with
increased urine output but decreased cardiac output/cardiac
index to 4.5/2.1 with an systemic vascular resistance of 400
to 500.
The thought was that the elevated central venous pressure was
artificially depressing the calculated systemic vascular
resistance; however, even with a normal central venous
pressure the calculated systemic vascular resistance was
lower than expected at around 600. The Neo-Synephrine was
weaned on hospital day four and switched to just dopamine
with Lasix boluses with a good renal response and a cardiac
output improvement of 6.5 and a calculated systemic vascular
resistance of approximately 500. The patient was continued
on this regimen for a goal of a negative 2 liters of fluid
output per day. Dopamine was titrated to maintain an MAP of
greater than 60. Dopamine and Swan-Ganz catheter were
discontinued on hospital day nine with a central venous
pressure of 27, pulmonary artery pressure of 65/27/45,
pulmonary capillary wedge pressure of 30, cardiac
output/cardiac index of 7.3/3.2, and a systemic vascular
resistance of 373. After dopamine was discontinued, the
patient's systolic blood pressure ranged in the high 70s to
low 80s without symptoms. The last measured central venous
pressure transduced from the triple lumen while in the
Coronary Care Unit was 22.
The patient was discharged to the medical floor on hospital
day 13 and continued on aggressive diuresis. Aldactone and
Zaroxolyn were eventually added and titrated to a maximum
regimen of Lasix 125 mg intravenously t.i.d., Aldactone 50 mg
p.o. q.d., and Zaroxolyn 5 mg p.o. q.d. which was tolerated
well. The patient's weight decreased from 94.9 kg to 76.4 kg
by hospital day 22 with a significant amount of fluid
overload still present. Dr. [**Last Name (STitle) 120**] has been discussing the
option of cardiac transplant with the patient; however, the
patient refuses at the moment and want to contemplate the
possibility once discharged from the hospital. The patient
will be followed by Congestive Heart Failure Clinic.
Dr. [**Last Name (STitle) **] is recommending cardiac catheterization for
further evaluation of cardiac function.
Digoxin level was elevated to 2.4 on admission likely
secondary to acute renal failure. Digoxin was discontinued
on admission, restarted on hospital day six, and maintained
within normal limits.
Low-dose captopril was started on hospital day seven and
slowly titrated up. It was eventually switched to Zestril to
avoid post dose hypotension.
(b) CORONARIES: The patient has severe coronary artery
disease. The patient was continued on aspirin and Lipitor.
We discontinued the gemfibrozil because of a low LDL and
triglyceride level.
(c) RHYTHM: The patient is AV paced at 70.
(d) VALVES: The patient had a mitral valve replacement and
was admitted on Coumadin with an elevated INR to 7. Coumadin
was held. Once INR fell below 2 (on hospital day 10),
heparin drip was started and PTT was maintained between 40
to 60 in the setting of slowly trending down hematocrit.
Coumadin was restarted on hospital day 21, post
gastrointestinal workup, with a goal INR of 2.5 to 3.5.
2. GASTROINTESTINAL: Chronic diarrhea was treated with
Imodium and Metamucil with good results. The patient was
started on Protonix for a questionable gastrointestinal
bleed. The patient has a history of a questionable
gastrointestinal bleed in combination with a large melanotic
stool and coffee-grounds via nasogastric lavage on hospital
day three, and a low hematocrit that continued to slowly
trend down with continuous guaiac-positive stools.
Helicobacter pylori was negative. Esophagogastroduodenoscopy
showed only a hiatal hernia. Colonoscopy showed significant
proctitis that was thought to likely be the etiology of her
decreasing hematocrit. The patient was started on Canasa per
rectum on hospital day 21 and was to follow up with the
Gastrointestinal Service.
3. HEMATOLOGY: Low hematocrit in the setting with elevated
INR. The patient was transfused a total of 6 units or packed
red blood cells during her hospital admission with a poor
response. The patient's hematocrit persisted between 25
and 30 for most of her hospital stay, sometimes stable and
otherwise slowly trending down. Abdominal/pelvic CT was
negative for retroperitoneal bleed on hospital day three. A
paracentesis was negative for peritoneal bleed on hospital
day three. Examination otherwise negative for signs of
bleeding. A gastrointestinal workup positive for
gastrointestinal bleed, eventually found to be due to
proctitis.
The patient's elevated INR: The patient's Coumadin was held
on admission, and the patient received 4 total units of fresh
frozen plasma and 2 mg of vitamin K. INR slowly trended down
to less than 2 on hospital day 10 when we began heparin drip
with a goal PTT of 40 to 60. This lower than normal goal was
instituted because of a questionable gastrointestinal bleed.
Coumadin was restarted on hospital day 21, post
gastrointestinal workup with a goal INR of 2.5 to 3.5.
4. RENAL: The patient's admission creatinine was 3.1 with
a baseline of approximately 1.1. Acute renal failure likely
secondary to decreased cardiac output. Acute renal failure
resolved with inotropic support and returned to baseline by
hospital day six. Digoxin levels were followed and
maintained within normal limits. The patient required
pyrimidine and Ditropan for bladder discomfort during her
hospital admission.
5. INFECTIOUS DISEASE: On admission the patient was found
to have a low systemic vascular resistance thought possibly
due to sepsis. Ultrasound-guided paracentesis was negative
for spontaneous bacterial peritonitis, blood cultures were
negative, urinalysis on admission was negative,
abdominal/pelvic CT was negative for abscess, and the patient
denied any symptoms of infection. On hospital day nine, the
patient was complaining of bladder discomfort and was found
to have a positive urinalysis. Urine cultures grew out
greater than 100,000 Escherichia coli. The patient only had
a temperature maximum of 99.5 and a white blood cell count
to 10.7. She was treated with a 5-day course of antibiotics.
6. NEUROLOGY: Head trauma in the setting of an elevated
INR. CT was negative for an acute bleed. Neurology
examination was followed while INR was elevated without
significant findings.
7. PULMONARY: The patient presented with mild congestive
heart failure on chest x-ray and lung examination. She was
well oxygenated on nasal cannula and easily weaned off of
oxygen requirement on hospital day 11.
8. ENDOCRINOLOGY: The patient was admitted with a
diagnosis of type 2 diabetes that had been controlled by
diet, not requiring insulin. Initially, we followed the
patient's fingersticks and started the patient on a regular
insulin sliding-scale. Fingersticks and regular insulin
sliding-scale were eventually discontinued because the
patient's serum glucose and fingersticks were usually within
normal range. The patient never required the use of the
insulin sliding-scale.
9. PSYCHIATRY: The patient has a history of depression.
Depression was well controlled with continuation of trazodone
and Zoloft.
10. MUSCULOSKELETAL: The patient with significant
deconditioning. Physical Therapy was following, and the
patient will likely be discharged to a rehabilitation center.
11. FLUIDS/ELECTROLYTES/NUTRITION: The patient was total
body overloaded but hypotensive secondary to decreased
cardiac output. The patient was fluid restricted and
aggressively diuresed with Lasix and eventually Aldactone and
Zaroxolyn with good results. Potassium, magnesium, and
phosphate were repleted as needed. The patient was placed on
a cardiac/diabetic diet.
12. CODE STATUS: The patient's code status was full.
DISCHARGE DISPOSITION: The patient was discharged to the
Medicine floor. An addendum is to follow with details of the
patient's final hospital course.
MEDICATIONS ON DISCHARGE: Will follow as well.
DISCHARGE INSTRUCTIONS: Will follow as well.
[**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**]
Dictated By:[**Last Name (NamePattern1) 13572**]
MEDQUIST36
D: [**2126-8-10**] 09:35
T: [**2126-8-14**] 08:56
JOB#: [**Job Number 13573**]
cc:[**Last Name (NamePattern4) 13574**] Name: [**Known lastname **], [**Known firstname 2045**] Unit No: [**Numeric Identifier 2046**]
Admission Date: [**2126-7-17**] Discharge Date:
Date of Birth: [**2067-10-24**] Sex: F
Service: Cardiology
ADDENDUM: The [**Hospital 1325**] hospital course since [**8-10**] -
Cardiovascular system: The patient underwent progressive
diuresis with 120 mg intravenous Lasix b.i.d. with a fluid
goal balance of negative 2 liters per day or 2 lbs per day.
The patient was responding well until [**8-12**], when she
had a cardiac catheterization showing a cardiac index of 1.9
and then improved to 2.1 with Milrinone. The patient was
transferred to the Coronary Care Unit after catheterization
on Milrinone and Dopamine drip and a Lasix drip for diuresis.
Because of poor urine output, Zaroxolyn and Aldactone were
held. It was attempted to wean the patient from Milrinone
but this had to be restarted to keep systolic blood pressures
greater than 80. Initially Dopamine was attempted to be
weaned on [**8-18**] and Aldactone was restarted. However,
by [**7-20**], it became clear that the patient's systemic
vascular resistance was decreasing on the Milrinone and it
was decided to hold the patient on a steady level of Dopamine
and to wean her from the Milrinone which was accomplished on
[**7-25**]. The patient was then maintained on a Dopamine
drip of 5 to 6 mcg/kg/min, and Enalapril was started for
afterload reduction. During this time, the patient was
recommended that her only chance of longterm survival would
be to undergo a cardiac transplant and she was referred for
evaluation by the [**Hospital 2047**], Cardiac
Transplant Team, however, on [**8-24**], the patient refused
to see the cardiac transplant surgeon, Dr. [**Last Name (STitle) 2048**]. At this
time it was decided to attempt to get the patient weaned off
of all pressors and to put her on a stable regimen of
diuretics and afterload reduction with Digoxin for increased
cardiac contractility and to allow her to return home in a
stable condition and spend time with her family while
evaluating her desire to have a transplant. Initially, the
patient tolerated the wean off of Dopamine. She was started
on Enalapril 2.5 mg b.i.d. and placed on stable Lasix
regimen. On [**2126-8-21**], the patient underwent
therapeutic paracentesis to treat her ascites which she
tolerated well, with a loss of more than 4 liters of fluid
from her peritoneum in the procedure without any
complications. The patient was continued to be transitioned
to an oral program with Lasix 120 mg b.i.d. and Zaroxolyn 5
mg b.i.d., Enalapril 5 mg b.i.d. with steady measurement of
her daily weights. On [**8-23**], her Swan was discontinued
and a triple lumen catheter was placed over the wire and the
patient was restarted on Coumadin with a goal stabilizing her
diuretic and ACE inhibitor program for at least 72 hours
while on 5243 when she would be discharged.
On [**8-24**], the patient was transferred on a regimen of
Coumadin 5 mg per day, Aldactone 25 mg b.i.d., Epogen, Lasix
160 mg b.i.d., Enalapril 5 mg b.i.d., Zaroxolyn 5 mg b.i.d.,
Digoxin .125 mg b.i.d. plus other noncardiac medications.
The patient remained stable while out of the unit on 5243,
however, by [**8-26**], she was gaining weight up to 1 to 1.5
kg/day with increasing oxygen requirement and increasing
creatinine. By [**8-27**], her creatinine had increased to
1.8, despite attempts to diurese with Lasix. By [**8-28**],
her creatinine had increased to 2.3. It was attempted to
give her normal saline fluids because her systolic pressures
had also decreased down to 60 or 70 and she was becoming
increasingly unsteady on her feet. It was thought that she
was overdiuresed and having prerenal failure, however, she
did not respond to the fluid boluses. Ultrasound of her
kidneys was negative for any kind of renal process or
obstruction causing her increase in creatinine, so the
patient was taken to the Catheterization Laboratory for right
heart catheterization which showed an initial venous
saturation of 49%. She was started on Dopamine drip at 5
mcg/kg/min. Her right atrial pressure was 20, PA pressures
were 72/30 with a mean of 44. Her PA saturation increased to
58%. Dopamine was increased to 10 mcg/kg/min. Her wedge
decreased from 35 to 28. Her PA diastolic decreased from 30
to 24. The patient became more awake. The patient showed
dramatic improvement on Dopamine and some low dose Nipride
was added for afterload reduction. This event demonstrated
that the patient had a very poor prognosis suggesting that
her renal failure was not due to vascular depletion but was
due to poor cardiac output.
The patient was transferred back to the Coronary Care Unit on
inotropic support following this procedure on [**8-28**].
Therefore inspite of progressive noninvasive management it
was determined that her options are very limited to either
cardiac transplant, left ventricular assist device which
would have been difficult because of her bowel prostheses or
home continuous intravenous inotrope which would be
considered a palliative measure. She was continued on
Dopamine and Nipride but did not tolerate the Nipride because
of drop in her pressures, so the Nipride was weaned off.
Dopamine was weaned down to a steady level. Her urine output
resumed with Lasix 60 mg intravenously per day. After
catheterization she put out 1100 cc of urine. Following
return to Dopamine, the patient continued to diurese with
steady improvement in her creatinine to 1.1, down from 2.3
prior to catheterization within two days of the procedure.
The patient's Dopamine was not able to be weaned below 8 and
plans were initiated to send the patient home on Dopamine
infusion with end stage congestive heart failure. Because
the patient required Dopamine continuous infusion, she was
required to stay in the Intensive Care Unit throughout the
remainder of her hospitalization.
On [**9-3**], the patient suddenly changed her mind and
expressed interest in having a cardiac transplant after being
made clear to her that Dopamine home infusion was only a
palliative care and she had at best weeks to months to live
at home on a Dopamine infusion. At this point she was stable
on Dopamine 8 mcg/kg/min regimen with Enalapril 2.5 mg b.i.d.
and Digoxin. An expedited transplant evaluation was pursued
with pulmonary function tests, carotid ultrasound, peripheral
ultrasound and all transplant bloodwork. Noninvasive
dopplers of her extremities demonstrated poor femoral blood
flow and on [**2126-9-11**], the patient underwent
angiography of her femoral and abdominal aorta with a
nonselective renal angiography. It was found that the
abdominal aorta was occluded distal to the renal arteries
with robust collaterals via the inferior mesenteric artery to
the pelvis. She had single bilateral renal arteries without
lesions. The right common femoral artery was occluded
proximally as it exited the retroperitoneum and the left
common femoral artery showed a similar filling defect.
Because of this occlusion of her aorta, the patient was
denied by the Transplant Surgery Team a position on the
transplant list and it was decided that her only option would
be palliative care at home with a home Dopamine infusion.
The patient was naturally very disappointed in this outcome
and has had difficulty accepting the outcome.
At this point the patient was on a stable regimen of Dopamine
8 mg/kg/min intravenously continuous infusion. Enalapril 5 mg
b.i.d., Digoxin .125 mg per day and it was decided that Lasix
20 mg per day and Coreg 3.125 mg per day would be added to
her regimen. Her other cardiac medications are Aspirin 325
mg per day, Lipitor 10 mg per day, Aldactone 25 mg per day
and Coumadin. The patient remained stable on this regimen.
On [**9-13**] the patient agreed to become again
Do-Not-Resuscitate status. She was referred for hospice home
care with management of her home Dopamine infusion.
Throughout this hospital stay the patient underwent constant
evaluation by physical therapy. She was seen by the
Psychiatric Staff on a number of occasions who recommended
that she continue her antidepressant regimen of Zoloft 150 mg
per day and Trazodone 50 mg at night. She was seen by the
electrophysiology service and was found not to qualify for a
biventricular pacer to help with cardiac function because of
severely dilated right ventricle. It was decided that an
implantable defibrillator would not be a useful device in
this patient because of her severe dilated cardiomyopathy
which would make a defibrillator likely to discharge
inappropriately. Her INR steadily increased while on
Coumadin and Heparin with a goal INR of 2.5 to 3.5 required
for her valve. Physical therapy recommended that she obtain
a walker with wheels to be delivered to the patient's home
and that she undergo some physical therapy while at home.
Her goals and plans on discharge are home intravenous
Dopamine for stabilization and enhancement of quality of life
with her family.
The prognosis on discharge and a median survival in a large
group of similar patients is weeks to a few months.
Individuals may have much shorter or longer survival.
Several weeks after discharge, if she is stable, she may
consider a retrial of a wean to an oral diuretic [**Doctor Last Name 932**] in the
hospital. Once discharged, we have recommended to bulk her
INR and Lasix, oral dosing will need simple adjustment in the
home environment. She will need INR, hematocrit, creatinine,
BUN, sodium, potassium measured every Tuesday and Thursday.
The data should be called to the Heart Failure Program nurse
practitioner, [**First Name8 (NamePattern2) 1518**] [**Last Name (NamePattern1) 2049**]. The Heart Failure Team will be
in regular phone contact with assigned hospice [**Hospital6 2050**] care. After the patient is settled, we will
arrange follow up visit to [**Hospital Ward Name **] 7 Heart Failure Clinic
with Dr. [**First Name4 (NamePattern1) 1263**] [**Last Name (NamePattern1) **].
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Coumadin 5 mg p.o. q. day
3. Percocet one to two tabs p.o. q. 4 to 6 hours prn for
pain
4. Milk of magnesia 30 cc p.o. b.i.d. prn constipation
5. Iron Sulfate 325 mg p.o. t.i.d.
6. Zoloft 150 mg p.o. q. day
7. Protonix 40 mg p.o. per day
8. Epogen 10,000 units subcutaneously q. Tuesday
9. Aspirin 325 mg p.o. per day
10. Lipitor 10 mg p.o. per day
11. Aldactone 25 mg p.o. every morning
12. Lasix 20 mg p.o. every morning
13. Coreg 3.125 mg p.o. b.i.d.
14. Tenasa 1 suppository per rectum q.h.s.
15. Enalapril 5 mg p.o. b.i.d.
16. Trazodone 50 mg p.o. q.h.s.
17. Digoxin .125 mg p.o. per day
18. Beconase 2 puffs intranasally b.i.d.
19. Dopamine 8 mg/kg/min continuous intravenous infusion for
a weight of 56 kg on discharge
DISCHARGE DIAGNOSIS:
1. End stage congestive heart failure, inotropic dependent
2. Coronary artery disease
3. Peripheral vascular disease
4. Depression
5. Proctitis
6. Chronic anemia of heart failure
DISCHARGE STATUS: Do-Not-Resuscitate, Do-Not-Intubate, she
is being discharged to home.
FOLLOW UP: Follow up with Dr. [**First Name4 (NamePattern1) 1263**] [**Last Name (NamePattern1) **], with home
hospice [**Hospital6 1346**] care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1600**], M.D. [**MD Number(1) 1601**]
Dictated By:[**Name8 (MD) 502**]
MEDQUIST36
D: [**2126-9-18**] 15:11
T: [**2126-9-18**] 18:21
JOB#: [**Job Number 2051**]
cc:[**Hospital 2052**]
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72,763
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Discharge summary
|
report
|
Admission Date: [**2180-4-27**] Discharge Date: [**2180-5-4**]
Date of Birth: [**2130-6-23**] Sex: F
Service: SURGERY
Allergies:
fluconazole
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
mesenteric ischemia
Major Surgical or Invasive Procedure:
Angiogram and Superior Mesenteric Artery Stenting
History of Present Illness:
Ms [**Known lastname 32153**] is a 49yF with known history of chronic mesenteric
ischemia ( post-prandial pain which is epigastric, sharp,). She
has only been able to eat small meals consisting of soup and
crackers. She has lost 50 lbs. She presents for elective
angiogram and potential stenting.
Past Medical History:
Chronic Mesenteric Ischemia, HTN, depression, hyperlipidemia,
C-section, cholecystectomy, kidney stone, tobacco abuse (down to
2 cigs/day prior to admission)
Social History:
Physical Exam:
Physical Exam:
Vitals: AFVSS
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: soft, ND, NT. No masses palpated, no peritonitis.
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2180-5-4**] 11:00AM BLOOD WBC-6.5 RBC-3.32* Hgb-9.9* Hct-30.1*
MCV-91 MCH-29.8 MCHC-32.9 RDW-15.7* Plt Ct-269
[**2180-5-4**] 05:00AM BLOOD Glucose-95 UreaN-10 Creat-0.5 Na-141
K-3.8 Cl-107 HCO3-27 AnGap-11
[**2180-5-4**] 05:00AM BLOOD Calcium-8.4 Phos-4.7* Mg-2.0
[**2180-4-28**]:
CT ANGIOGRAM: There is arterial pooling of contrast in the mid
jejunum
(4A:82) which increases substantially on venous phase
(4B:263-277). A stent is seen in the ostium of the superior
mesenteric artery which appears patent. Narrowing of the origin
of the celiac axis and narrowing of the origin of the inferior
mesenteric artery with post-stenotic dilation are again seen.
Diffuse non-calcified atherosclerotic plaque along the aorta is
again seen. Visualized vasculature appears patent. No
concerning lytic or sclerotic osseous lesions are seen.
IMPRESSION: Brisk active arterial extravasation in the
mid-jejunum
Brief Hospital Course:
Ms. [**Known lastname 32153**] was brought to the operating room electively on
[**2180-4-27**] and underwent a superior mesenteric artery stenting for
her symptoms of chronic mesenteric ischemia. The procedure was
without complications. She was closely monitored in the PACU and
then transferred to the VICU where she remained hemodynamically
stable. On POD 1 she experienced abdominal pain and melena with
anemia. A CTA showed active extravasation of blood into the
lumen of the mid-jejunum. ACS was consulted and felt that the
patient was hemodynamically stable and with a low volume bleed
so no intervention was warranted. She received a total 6 units
PRBCs. Her diet was gradually advanced to regular which she
tolerated without pain. Her stools have been black but her HCT
has stabilized around 30. She is ambulatory ad lib. She was
discharged to home on POD # 7 in stable condition. Follow-up
has been arranged with Dr. [**Last Name (STitle) 174**] of GI and Dr. [**Last Name (STitle) **].
Medications on Admission:
fluoxetine 40mg', simvastating 20mg', ASA 81mg', prescribed
pantoprazole but stopped taking
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Mesenteric ischemia
Hyperlipidemia
Depression
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 an anngiogram and
stenting of the superior mesenteric artery. After the procedure,
you had some problems with pain and gastrointenstinal bleeding.
This was felt to be secondary to increase blood flow to your
bowel after the procedure. We did not need to do any additional
procedures and the bleeding subsided.
Division of Vascular and Endovascular Surgery
Mesenteric Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 81mg (enteric coated) once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2180-5-25**] at 10:15 AM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: VASCULAR SURGERY
When: WEDNESDAY [**2180-6-7**] at 11:30 AM [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2180-5-4**]
|
[
"285.1",
"311",
"272.4",
"783.21",
"401.9",
"578.9",
"998.11",
"557.1",
"447.4",
"305.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"00.45",
"39.50",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
3629, 3635
|
2088, 3094
|
290, 342
|
3725, 3725
|
1157, 2065
|
5686, 6307
|
3237, 3606
|
3656, 3704
|
3120, 3214
|
3876, 5663
|
899, 1138
|
231, 252
|
370, 670
|
3740, 3852
|
692, 852
|
869, 869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,954
| 175,450
|
18725
|
Discharge summary
|
report
|
Admission Date: [**2158-8-28**] Discharge Date: [**2158-9-5**]
Date of Birth: [**2091-9-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
relatively asymptomatic
Major Surgical or Invasive Procedure:
[**2158-8-29**] AVR ( 27mm [**Company 1543**] Mosaic porcine valve)
History of Present Illness:
66 yo male with known AI/bicuspid AV and increasing LV
dimensions. Cath showed clean coronaries. Referred for AVR.
Past Medical History:
AI
overactive bladder
HTN
BPH
hypercholesterolemia
Past Surgical History:
repair cleft lip
pilonidal cystectomy
L eye muscle surgery
tonsillectomy
Social History:
Occupation:dentist
Last Dental Exam:several months ago
Lives with: wife [**Name (NI) **]: Caucasian
Tobacco: 5 PYH/ quit [**2117**] ETOH: several drinks per month
Family History:
(parents/children/siblings CAD < 55 y/o): Father
+CHF
Physical Exam:
Pulse:61 Resp: 20 O2 sat:
B/P Right:112/70 Left: 112/72
Height: 68" Weight: 162 #
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera, OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 SEM with faint
disatolic
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM or CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema -trace BLE
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam, MAE [**3-28**] strengths
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: murmur radiates to both carotids
Pertinent Results:
[**2158-9-4**] 05:15AM BLOOD WBC-5.5 RBC-3.35* Hgb-10.0* Hct-29.9*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.1 Plt Ct-161
[**2158-8-31**] 04:59AM BLOOD PT-13.7* PTT-31.0 INR(PT)-1.2*
[**2158-9-4**] 05:15AM BLOOD Glucose-98 UreaN-16 Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-26 AnGap-12
PA AND LATERAL VIEWS OF THE CHEST.
REASON FOR EXAM: S/P AVR.
Comparison is made to prior study [**2158-8-31**].
Mild cardiomegaly is stable. Small bilateral pleural effusions
with adjacent atelectasis, left greater than right, are
improved. There is no CHF or pneumothorax.
Ill-defined opacity in the anterior segment right upper lobe is
new, could be atelectasis, attention in this area should be
performed in the followup
studies to exclude developing infection. Sternal wires are
aligned. The
patient is status post AVR.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 51318**] (Complete)
Done [**2158-8-29**] at 3:17:54 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2091-9-26**]
Age (years): 66 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease and ? Ascending aortic
dilatation
ICD-9 Codes: 424.1
Test Information
Date/Time: [**2158-8-29**] at 15:17 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: *4.0 cm <= 3.4 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Moderately dilated
ascending aorta.
AORTIC VALVE: Bicuspid aortic valve. No AS. Moderate to severe
(3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. The aortic valve is
bicuspid. There is no aortic valve stenosis. Moderate to severe
(3+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results [**First Name9 (NamePattern2) 51319**] [**Known lastname **]
before bypass.
POST-BYPASS:
Preserved biventricular functin LVEF >55%.
There is a bioprosthetic valve in the aortic position (#27 per
surgeons) No AI or perivalvular leaks, Peak gradient less than 6
mm Hg on multiple measurements.
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, Interpreting
physician [**Last Name (NamePattern4) **] [**2158-8-30**] 14:59
Brief Hospital Course:
Admitted [**8-28**] for cardiac cath which showed clean coronaries.
Underwent surgery with Dr. [**Last Name (STitle) **] on [**2158-8-29**] for aortic valve
replacement (#27mm [**Company 1543**] mosaic). He was transferred to the
CVICU in stable condition on phenylephrine and propofol drips.
Extubated that evening and transferred to the stepdown unit on
POD#2. He was started on a low dose betablocker which was
titrated gently due to asymptomatic hypotension. He was diuresed
toward his pre-op weight. His chest tubes and temporary pacing
wires were removed per protocol. He was evaluated by physical
therpay for strength and consitioning and was cleared for
discharge. He had some asymptomatic hypotension and his beta
blocker was decreased. He continued to progress and was
discharged to home is stable condition on POD #7.
Medications on Admission:
ASA 160 mg daily
Clonazepam at bedtime
simvastatin 20 mg daily
Flomax 0.4mg daily
Inderal 20mg [**Hospital1 **]
Vit. D 1000 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
Disp:*75 Tablet(s)* Refills:*2*
8. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
9. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain/muscle spasm.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 40198**] VNA
Discharge Diagnosis:
Aortic Insifficiency s/p AVR (porcine)
overactive bladder
Hypertension
BPH
hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
no lotions, creams, ointments or powders on any incision
shower daily and pat incision dry
no driving for one month AND off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Followup Instructions:
Please schedule the following appointments:
Dr. [**Last Name (STitle) **] in [**11-25**] weeks
Dr. [**First Name (STitle) 1124**] in [**12-27**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2158-9-5**]
|
[
"600.01",
"780.62",
"E878.1",
"746.4",
"596.54",
"429.9",
"285.9",
"511.9",
"596.51",
"424.1",
"401.1",
"333.1",
"287.4",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"88.56",
"39.61",
"37.23",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
8741, 8797
|
6521, 7353
|
344, 414
|
8937, 8944
|
1824, 6498
|
9291, 9545
|
949, 1005
|
7537, 8718
|
8818, 8916
|
7379, 7514
|
8968, 9268
|
654, 729
|
1020, 1805
|
281, 306
|
442, 558
|
580, 631
|
745, 933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,319
| 154,972
|
338
|
Discharge summary
|
report
|
Admission Date: [**2113-11-8**] Discharge Date: [**2113-11-22**]
Date of Birth: [**2029-9-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
increasing angina
Major Surgical or Invasive Procedure:
[**2113-11-9**] CABG x5 (LIMA to LAD, SVG to RCA seq. to PDA, SVG to
OM, SVG to DIAG)
[**2113-11-8**] cardiac cath with IABP
History of Present Illness:
84 yo w/several month h/o exertional
shoulder discomfort which is relieved w/NTG. He has had 3 day
h/o
worsening shortness of breath and shoulder pain. On admission
he
recieved nitroglycerin and his chest pain was relieved. On EKG
he was found to have STD laterally and
apically as well as QW anteriorly as well as positive troponin
with an acute MI.
This pm on the floor the patient developed worsening confusion
and hypotension. He was taken to the cath lab where he was
found
to have severe left main disease and developed hypotension with
injection of the coronary arteries. He required an intra aortic
balloon pump for hemodynamic stabilization and decision was made
to take him emergently to the operating room.
Past Medical History:
Coronary artery disease
type 2 diabetes
peripheral arterial disease
hypertension
hyperlipidemia
peptic ulcer disease
severe GI bleed [**2106**]
trigeminal neuralgia
Left lumbar radiculopathy secondary to degenerative
disc disease
Past Surgical History
s/p bilateral CEA
s/p appendectomy
s/p bilat cataract surgery
Social History:
The patient lives alone, widowed, three children. He is now
retired, former teacher. He denies alcohol, drug. Tobacco use 30
years 1ppd. quit 30 years ago.
Family History:
from OMR: father MI at 57. MI in several uncles. Mother
reportedly died from peritonitis.
Physical Exam:
Admission Physical Exam
Pulse:86 Resp: O2 sat:
B/P Right: 120/85 Left:
Height: 65" Weight:175 lbs
General:
Skin: Dry [x] intact [x]
HEENT: purulent drainage/injected sclera in R eye for last few
weeks PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] __1+___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:IABP Left:2+
DP Right:- Left:-
PT [**Name (NI) 167**]:dopp Left:dopp
Radial Right:2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
Conclusions
PRE-BYPASS: No spontaneous echo contrast 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. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is severe regional left
ventricular systolic dysfunction with akinesis of the apex and
distal anterior, inferior, septal, and lateral walls. There is
hypokinesis of the basal to mid anterior, anterolateral, and
inferolateral walls. Overall left ventricular systolic function
is severely depressed (LVEF= 25-30 %). The remaining left
ventricular segments are hypokinetic. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. There is an intraaortic balloon pump with the
tip 5 cm distal to the aortic arch. The aortic valve leaflets
(3) are mildly thickened. Mild to moderate ([**11-20**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of
the results at time of surgery.
POST-BYPASS: The patient is sinus rhythm. The patient is on an
epinephrine infusion. Left ventricular function is improved with
an EF of 40-45%. Right ventricular function is unchanged.
Regional wall motion abnormalities are improved with mild global
hypokinesis. Mitral regurgitation is unchanged. Aortic
regurgitation is unchanged. Tricuspid regurgitation is
unchanged. The aorta is intact post-decannulation.
[**2113-11-17**] 06:13AM BLOOD WBC-18.6* RBC-4.10* Hgb-12.2* Hct-37.6*
MCV-92 MCH-29.8 MCHC-32.6 RDW-14.4 Plt Ct-325
[**2113-11-8**] 03:15PM BLOOD WBC-13.0* RBC-4.15* Hgb-12.1* Hct-37.9*
MCV-91 MCH-29.1 MCHC-31.9 RDW-12.9 Plt Ct-299
[**2113-11-14**] 04:14AM BLOOD PT-12.9* PTT-29.7 INR(PT)-1.2*
[**2113-11-8**] 08:10PM BLOOD PT-12.3 PTT-66.7* INR(PT)-1.1
[**2113-11-17**] 06:13AM BLOOD Glucose-126* UreaN-43* Creat-1.1 Na-136
K-4.5 Cl-99 HCO3-32 AnGap-10
[**2113-11-8**] 03:15PM BLOOD Glucose-201* UreaN-49* Creat-1.7* Na-139
K-5.6* Cl-105 HCO3-27 AnGap-13
[**2113-11-22**] 04:13AM BLOOD WBC-17.2* RBC-3.69* Hgb-11.1* Hct-34.7*
MCV-94 MCH-30.1 MCHC-31.9 RDW-14.2 Plt Ct-500*
[**2113-11-21**] 04:17AM BLOOD WBC-22.9* RBC-4.02* Hgb-12.2* Hct-38.5*
MCV-96 MCH-30.3 MCHC-31.7 RDW-14.1 Plt Ct-504*
[**2113-11-20**] 05:30PM BLOOD WBC-21.3* RBC-4.07* Hgb-12.2* Hct-38.3*
MCV-94 MCH-30.0 MCHC-31.9 RDW-14.1 Plt Ct-509*
[**2113-11-19**] 07:35PM BLOOD WBC-21.3* RBC-3.95* Hgb-11.7* Hct-36.8*
MCV-93 MCH-29.7 MCHC-31.9 RDW-14.0 Plt Ct-465*
[**2113-11-22**] 04:13AM BLOOD Glucose-93 UreaN-39* Creat-1.1 Na-138
K-5.2* Cl-108 HCO3-24 AnGap-11
[**2113-11-21**] 04:15PM BLOOD Na-139 K-5.1 Cl-108
[**2113-11-21**] 11:20AM BLOOD UreaN-41* Creat-1.3* Na-136 K-5.7* Cl-105
[**2113-11-21**] 04:17AM BLOOD Glucose-113* UreaN-43* Creat-1.1 Na-137
K-5.5* Cl-107 HCO3-21* AnGap-15
[**2113-11-20**] 05:30PM BLOOD UreaN-46* Creat-1.3* Na-137 K-5.2* Cl-105
Brief Hospital Course:
Admitted from ER to cardiology service on [**11-9**] with acute
Myocardial Infarction. Taken to cath lab that evening and found
to have critical Left Main, 3Vessel Coronary Artery Disease and
IABP placed. He was taken emergently to OR with Dr. [**Last Name (STitle) 914**] in
the early AM [**11-10**] for Emergent coronary artery bypass grafting
x5 on intra- aortic balloon pump, with the left internal mammary
artery to the left anterior descending coronary artery,reversed
saphenous vein single graft from the aorta to the second
diagonal coronary artery, reversed saphenous vein single graft
from the aorta to the first obtuse marginal coronary artery, as
well as reversed saphenous vein double sequential graft from the
aorta to the distal right coronary artery and the posterior
descending coronary artery/ Partial resection of mediastinal
mass dictated separately by Dr. [**Last Name (STitle) 3140**]. CARDIOPULMONARY
BYPASS TIME: 103 minutes.CROSS-CLAMP TIME: 75 minutes.
Transferred to the CVICU in stable condition on titrated
epinephrine, phenylephrine, Dobutamine and propofol drips.POD#2
the IABP was weaned and discontinued.Pressors were ultimately
weaned to off. Lines and drains were discontinued per protocol.
POD#3 He was neurologically intact, hemodynamically stable, and
weaned to extubate. Beta-blocker/Statin/aspirin and diuresis
were initiated. An ACE-I was added for afterload reduction -
however, this was stopped prior to discharge secondary to
persistent hyperkalemia. Mr. [**Known lastname 3141**] had postop confusion that
improved back to baseline, he slowly progressed and on [**11-15**] he
was transferred to the step down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. Wound care was consulted for impaired skin integrity
of his stage III sacral decub - this was treated with Mepilex
and daily dressing changes. Postoperative leukocytosis was
monitored with surveillance cultures and repeat CXRs. A small
amount of sternal drainage was evident and he was started on
empiric antibiotics. ID was consulted and CT of the chest
revealed no source of infection. Cultures were all negative at
the time of discharge - blood culture was pending with no growth
to date. His WBC had decreased to 17.2 from 22.9 and he remained
afebrile. He will be discharged to rehab with Keflex x 7 days
for resolving leukocytosis per ID recommendations. CBC to be
checked on Friday [**11-24**] with results called to cardiac surgery
office. He continued to slowly progress and on POD 13 he was
cleared for discharge to [**Hospital **] [**Hospital 1456**] rehab. All follow up
appointments were advised. He will return to the cardiac surgery
office in 1 week for a wound check.
Medications on Admission:
pravastatin 40mg daily
amlodipine-benazepril 10mg/20mg daily
carbamazepine 200mg twice daily as needed for facial pain
glyburide 5mg daily
metoprolol tartrate 50mg daily
nitroglycerin 0.4mg prn
omeprazole 20mg twice daily
aspirin 81mg daily
Plavix - last dose:600mg [**11-9**]
IV integrilin and heparin drip prior to OR
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q2H (every 2 hours) as
needed for wheezing.
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Regular Insulin Sliding scale ACHS
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2
Units 2 Units 2 Units 0 Units 160-199 mg/dL 4 Units 4 Units 4
Units 2 Units 200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-279 mg/dL 8 Units 8 Units 8 Units 6 Units 280-320 mg/dL 10
Units 10 Units 10 Units 8 Units
12. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Q PM.
13. glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Q AM.
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
15. heparin Sig: One (1) 5000 units Subcutaneous three times a
day for 1 months.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
coronary artery disease s/p cabg x5
acute myocardial infarction
type 2 diabetes
hypertension
hyperlipidemia
peripheral arterial disease
peptic ulcer disease
severe GI bleed [**2106**]
trigeminal neuralgia
Left lumbar radiculopathy secondary to degenerative
disc disease.
Past Surgical History
s/p bilateral CEA
s/p appendectomy
s/p bilat cataract surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema, no drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ lower extremity
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**] Phone:[**Telephone/Fax (1) 170**] Date/Time: [**2113-12-18**] at
1:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Wound Check on [**11-30**] at 10:00 AM at [**Hospital Ward Name **] Buliding [**Hospital Unit Name **] -
please evaluate Stage III decub at the time of wound check
REHAB TO CHECK CBC on Friday [**11-24**] and call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3142**] in
cardiac surgery office at [**Telephone/Fax (1) 170**] with results
PCP/Cardiologist:Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2114-1-10**]
at 12:00
**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:[**2113-11-22**]
|
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"428.0",
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"599.0",
"785.51",
"285.9",
"786.6",
"V15.3",
"041.84",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
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"34.3",
"97.44",
"88.53",
"36.14",
"99.20",
"88.56",
"96.71",
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] |
icd9pcs
|
[
[
[]
]
] |
10617, 10717
|
5816, 8559
|
327, 453
|
11116, 11357
|
2590, 5793
|
12198, 13103
|
1733, 1826
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8930, 10594
|
10738, 11095
|
8585, 8907
|
11381, 12175
|
1841, 2571
|
270, 289
|
481, 1205
|
1227, 1543
|
1559, 1717
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,236
| 186,061
|
52419
|
Discharge summary
|
report
|
Admission Date: [**2194-3-14**] Discharge Date: [**2194-3-22**]
Date of Birth: [**2112-2-19**] Sex: F
Service: MEDICINE
Allergies:
Belladonna Alkaloids
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
hypoxia, somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 82 year-old female with a history of MDS, PE on
Lovenox, CAD, Crohn's who presents with increased O2
requirement. At baseline, she uses approximately 2.5L of O2 at
home. Her daughter noted that yesterday, she was satting in the
mid 80s, and increased her O2 to 3-4L. The patient seemed more
somnolent and confused over the last day. She brought her to
the ED for this. Of note, daughter states that patient has not
been eating much lately, and continues to have diarrhea.
.
In the ED, her initial VS were 96.7, 119/95,65,23, 95% 4L. She
was noted to have bilateral crackles on exam. CXR was
consistent with volume overload, left pleural effusion +/-
consolidation. She was then noted to be hypotensive with BP
69/12. She was given a 250 cc bolus with improvement to SBP
110. She then was noted again to be hypotensive vitals 80/22,
62, 92% 4L. She was to be given another 500 cc bolus when they
realized she had pulled out her IV. They discussed with the
patients daughter, the HCP, about a [**Name (NI) 14938**], but the daughter
refused. They placed another 18G and gave her another 500 cc
bolus. She is on chronic prednisone (18 mg daily), so she was
given 10 mg decadron. Also, she was given levofloxacin and
vancomycin in the ED as well as a combivent. No ABG was done.
There was another lengthy discussion in the ED regarding goals
of care, which has been an issue in the past, and currently her
daughter reports that she is DNI, but not DNR. Her last lovenox
dose was yesterday.
.
ROS: patient did not give ROS; per daughter, no fevers, nausea,
vomiting, chest pains. She does report decreased UOP with
decreased PO intake and diarrhea recently.
Past Medical History:
#. Anemia, due to renal failure, anemia of chronic disease, and
myelodysplastic syndrome; previously on epo weekly and requiring
regular transfusions, multiple positive anti-RBC antibodies.
#. Chronic bilat LE edema
#. Crohn's disease
#. breast CA s/p s/p R lumpectomy and XRT 13 yrs ago
#. GERD
#. CAD s/p NSTEMI '[**89**]
#. s/p CCY 10 yrs ago
#. HTN (does not appear to be on home meds)
#. hx of bilateral DVTs and saddle embolus in [**2190**], had been on
warfarin.
#. CRI, baseline cr 1.5-1.8
#. MVA 20 years ago with intracranial bleed
Social History:
Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments.
Family History:
non-contributory
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2194-3-14**] 04:25PM BLOOD WBC-5.2 RBC-2.83* Hgb-10.2* Hct-32.7*
MCV-116* MCH-36.3* MCHC-31.3 RDW-19.0* Plt Ct-219
[**2194-3-14**] 04:25PM BLOOD Neuts-60.7 Lymphs-31.2 Monos-6.7 Eos-1.0
Baso-0.4
[**2194-3-14**] 03:10PM BLOOD PT-11.0 PTT-20.7* INR(PT)-0.9
[**2194-3-14**] 03:10PM BLOOD Glucose-88 UreaN-27* Creat-2.3* Na-138
K-5.2* Cl-101 HCO3-30 AnGap-12
[**2194-3-14**] 03:10PM BLOOD ALT-5 AST-15
[**2194-3-14**] 03:10PM BLOOD Lipase-39
[**2194-3-14**] 03:10PM BLOOD Albumin-3.5 Phos-4.0 Mg-2.0
[**2194-3-14**] 03:10PM BLOOD GreenHd-HOLD
[**2194-3-14**] 08:40PM BLOOD Type-ART pO2-68* pCO2-74* pH-7.23*
calTCO2-33* Base XS-0
[**2194-3-14**] 08:40PM BLOOD Lactate-0.6
[**2194-3-15**] Radiology CT CHEST W/O CONTRAST
IMPRESSION:
1. Slightly increased right pleural effusion which is now
moderate, and
unchanged small left pleural effusion. Minimal residual opacity
in the
posterior left upper lobe from previously seen consolidation.
2. Thickening of the mid to distal esophagus with fatty
infiltration in the
distal esophageal wall, suggesting esophagitis, which may relate
to the
patient's moderate-sized axial hiatal hernia.
3. Unchanged hypoattenuating left thyroid lesion, for which
ultrasound is
recommended.
[**2194-3-19**] Radiology CHEST (PA & LAT)
IMPRESSION: Unchanged appearance of mild pulmonary edema and
bilateral
pleural effusions.
Brief Hospital Course:
82 year-old female with a history of PE, MDS, CKD, anemia, CAD
who presents with hypoxia and hypotension.
# Hypoxic/hypercapnic respiratory failure: Patient presented
with acute on chronic hypoxia, as she has an oxygen requirement
at home of 2.5L. A CXR on admission demonstrated pneumonia and
a chest CT confirmed the presence of an infiltrate and also
demonstrated bilateral pleural effusions, right greater than
left. Patient's hypoxia was thought to be secondary to
pneumonia, pleural effusions, and diastolic heart failure, and
her hypercapnia was thought to be secondary to muscular weakness
and possibly obstructive sleep apnea (does not carry this
diagnosis). She was continued on levofloxacin (day 1=[**3-14**]) and
vancomycin (day 1=[**3-15**]). She will likely require BiPAP qhs
chronically. Vancomycin was d/c'd prior to transfer out of the
ICU [**3-17**]. Patient remained stable following transfer to floor.
She was continued on a 10day course of levofloxacin. She did
not tolerate increased doses of lasix. However, she was
continued on 10mg daily (up from home dose qod) and she had
marked improvement of her anasarca. Given the severity of
right-sided heart failure/diastolic heart failure, and expected
recurrent exacerbations the CHF service was consulted and
recommend continued diuresis with lasix qod/prn, with dosing
until blood pressure decreases or Cr increases. She was also
continued on metoprolol 12.5. Her weight at time of discharge
was 126.5lbs. She electively did not use BiPAP on the floor.
# Pneumonia: Patient was continued on levofloxacin. Vancomycin
d/c'd after 2 days on [**3-17**].
# Hypotension: Patient was hypotensive at presentation with a
SBP in the 80s and was thought to be relatively volume deplete
in the setting of diarrhea and poor po intake. Her SBP improved
to the 100s after IVF administration in the ED and arrival to
the ICU. Her blood pressure remained stable during this
hospitalization.
# Altered mental status: There was some concern initially that
patient's mental status was altered and a head CT was negative
for an acute process. Her mental status was at baseline per her
daughter and this remained stable.
# DVT and PE: Patient has a history of DVT/PE and is on lovenox
at home, with LMW heparin levels checked regularly (last checked
on [**2194-3-4**], LMW hep = 1.04). She was continued on her lovenox
dose of 70 mg daily.
# CRI: Patient's creatinine was at it's baseline (1.8-2.3) and
medications were renally dosed. Her Cr did increase slightly to
2.5 with extra lasix and was 2.4 at day of discharge.
#Hemorrhagic bullous s/p rupture: Wound healing nicely and large
blood clot was debrided by plastic surgery. Healthy tissue was
seen underneath the clot. She will have home wound care and f/up
with plastic surgery.
# MDS: Followed by Dr. [**Last Name (STitle) **] of [**Hospital1 18**]. Has received multiple
blood transfusions in past.
# Code: DNR/DNI- confirmed with daughter
#Social: Multiple discussion were had with the patient and her
daughter throughout this hospitalization regarding goals of care
and prognosis. The patient and daughter seemed to be in
agreement about continued medical care, with avoiding aggressive
interventions, such as cardiopulmonary resuscitation and other
procedures. Given the severity of her right heart failure and
delicate fluid balance (preload dependence/diastolic CHF), and
hence likely course of continued CHF exacerbations and frequent
hospitalizations, the patient was seen by the palliative care
service to introduce the services offered by additional
programs/home hospice, The family was not interested in hospice
services at this time,but will continue with a visiting nurse
and other services as needed.
Medications on Admission:
1) Albuterol 1-2 puffs Q4-6H PRN wheezing
2) Alendronate 70 mg qSat
3) Calcium carbonate 500 mg TID
4) Enoxaparin 70 mg Q24H
5) Epogen 40,000 units qweek
6) Folic acid 1 mg daily
7) Furosemide 10 mg QOD
8) Mesalamine 1200 mg daily
9) Toprol 25 mg daily
10) Omeprazole 20 mg [**Hospital1 **]
11) Prednisone 18 mg daily
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
Disp:*12 Tablet(s)* Refills:*2*
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*60 Tablet(s)* Refills:*2*
14. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) units
Subcutaneous Q24H (every 24 hours).
15. Prednisone 10 mg Tablet Sig: Eighteen (18) mg PO DAILY
(Daily).
16. Epoetin Alfa 10,000 unit/mL Solution Sig: 40,000 units
Injection once a week.
17. Outpatient Lab Work
Outpatient Lab Work
Please have your sodium, potassium, bicarbonate, chloride, BUN,
creatinine, calcium, magnesium, and phosphate next Wednesday
[**3-26**]. Please have results sent to attention Dr. [**Last Name (STitle) 3357**] Phone
[**Telephone/Fax (1) 4606**]
18. Home Oxygen
Diagnosis: congestive heart failure
Please start nasal cannula 2 L/min to keep sats >94%
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
1)Acute on chronic diastolic and right-sided heart failure
2)Hypercarbia
3)Pneumonia
4)Chronic Kidney Disease
Discharge Condition:
Stable; on 2L NC; Weight 126lbs in the hospital
Discharge Instructions:
You were hospitalized with low oxygen levels and hypercarbia
(high carbon dioxide). This was likely due to congestive heart
failure, possible pneumonia, and weakness.
.
You were given lasix to try and get rid of some of the fluid in
your
lungs and the swelling of your arms and legs. Please take all
your medications as prescribed.
.
You should weigh yourself when you arrive home today and be
weighed everyday. On day of discharge you weighed 126.5 pounds.
If you gain more than 3 pounds you should take an extra dose of
you lasix. Also, you should not eat more than 2 grams of salt in
your diet a day. You should also drink less than 1200 ml of
fluid a day .
.
You have one more day of an antibiotic treatment.
.
Regarding your prednisone, you should see Dr.[**Last Name (STitle) 3708**] to discuss
decreasing the dose of this. It can be detrimental to be on high
doses of steroids for an extended period of time.
.
Please have your labs drawn to check your electrolytes and
hematocrit this week. Enclosed is a prescription for a lab draw.
You should have your kidney function monitored every two weeks.
.
Call your primary physician with concerns or questions, and
return to the emergency department if you have fever greater
than 101, low oxygen, shortness of breath, bleeding, increased
pain, or other alarming symptoms.
Followup Instructions:
Please call the plastic surgery [**Telephone/Fax (1) 4652**] for a follow-up
appointment on [**4-4**]. You should tell them that you were
seen in the hospital and instructed to go to that clinic.
.
Please call Dr. [**Last Name (STitle) 3357**] for close follow up on discharge.
Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] for follow up of you MDS.
.
You should follow up with Dr [**Last Name (STitle) 3708**] of GI and discuss tapering
your prednisone down.
|
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
11752, 11827
|
5649, 7618
|
301, 308
|
11981, 12031
|
4268, 5626
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242, 263
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336, 2019
|
7634, 9401
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2041, 2586
|
2602, 3477
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,513
| 104,888
|
45799+58854
|
Discharge summary
|
report+addendum
|
Admission Date: [**2126-1-24**] Discharge Date: [**2126-2-4**]
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 79-year-old woman
admitted from [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **], where she has been living since
[**2125-9-20**] with acute respiratory distress, hypoxia with
oxygen saturation registered at 50% to 70%. In the Emergency
department, the patient was evaluated for hypoxia and perfuse
secretions per her trach. There were thick, yellow sections
suctioned. The oxygen saturation, following suctioning,
improved to 98% on room air and 100% on full trach mask. The
patient's trach was changed from cuff trach and she was
placed on the ventilator. Chest x-ray revealed right greater
than left infiltrate consistent with pneumonia. The patient
was so Levofloxacin and Vancomycin. Arterial line was placed
and the patient was transferred to the medical ICU.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft.
2. Aortic stenosis status post aortic valve replacement.
3. Hypertension.
4. Elevated cholesterol.
5. Diabetes mellitus.
6. Chronic renal insufficiency.
7. Depression.
8. History of cerebrovascular accident in [**2118**].
9. History of atrial fibrillation.
MEDICATIONS ON ADMISSION:
1. Lorazepam 0.25 mg p.o.q.d. and p.r.n.
2. Enteric coated aspirin 325 mg p.o.q.d.
3. Colace 100 mg p.o.q.d.
4. Effexor 50 mg q.a.m.; 25 mg q.p.m.
5. Levoxyl 150 mcg p.o.q.d.
6. Metoprolol 25 mg p.o.b.i.d.
7. Trazodone 50 mg p.o.q.h.s.
8. Nitroglycerin 0.4 mg sublingual p.r.n.
9. Pureed tube feeds per G tube.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: No alcohol, no smoking.
PHYSICAL EXAMINATION: Admission physical examination
revealed the following: VITAL SIGNS: 98.6, blood pressure
184/70, heart rate 83, oxygen saturation 99% on 100% trach
mask. The patient is alert and responsive to commands.
HEENT: Pupils equal, round, and reactive to light.
Extraocular muscles are intact. Sclerae anicteric.
Oropharynx clear. CARDIOVASCULAR: Regular rate and rhythm,
normal S1 and S2; 2/6 systolic ejection murmur appreciable at
the left upper sternal border. LUNGS: Lungs revealed
bilateral coarse rhonchi. ABDOMEN: Soft, nontender,
nondistended with active bowel sounds. EXTREMITIES: No
appreciable edema.
LABORATORY DATA: Admission laboratory studies revealed the
following: white blood count 19.4, hematocrit 42.5, platelet
count 223,000, sodium 126, chloride 95, bicarbonate 20, BUN
26, creatinine 1.2, and glucose 232. Initial blood gas
revealed the pH of 7.31, pCO2 55, pAO2 of 63 on 100%
nonrebreather. Chest x-ray revealed bilateral infiltrates
right greater than left, urinalysis negative.
HOSPITAL COURSE: (by system)
PULMONARY: The patient was admitted for respiratory distress
with copious-purulent secretions from the trach and evidence
of pneumonia by chest x-ray. The patient was afebrile, but
with elevated white blood count. The patient was treated for
a right-sided pneumonia, possibly aspiration in origin with a
ten-day course of Levaquin and Vancomycin. The patient was
treated with Vancomycin and given a history of Methicillin
resistant Staphylococcus aureus. Sputum cultures were
negative, except for evidence of oropharyngeal flora.
Bronchoalveolar lavage was performed on the second day of
admission, which revealed relatively normal-looking bronchi.
Lavage was positive for polys and gram-negative rods, which
turned out to be oropharyngeal flora. Legionella cultures,
fungal cultures, and RSV cultures were negative. Blood
cultures remained negative throughout this hospitalization
with the exception of one bottle, which grew out
Vancomycin-resistant Enterococcus thought to be contaminate
versus colonized as it was repeated and not reproducible.
The patient was evaluated by the Interventional Pulmonary
Service, namely Dr. [**Last Name (STitle) **], for trach, which had been placed
within the last year for the diagnosis of tracheomalacia
status post prolonged intubation for status post coronary
artery bypass graft. The patient had had a prior tracheal
stent placed, which had been discontinued and has since been
on a trach mask since that time with plans for a larger trach
versus repeat stenting. Bronchoscopy on this admission
revealed mild tracheitis, but otherwise, normal trachea. it
was thought that her problems with secretions and
intermittent tracheal obstruction were largely related to
supraglottic edema secondary to persistent regurgitation
versus chronic aspiration. Bronchoscopy revealed
supraglottic edema as noted. This had been confirmed to a
lesser extent by the patient's ENT physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
The patient was again evaluated by ENT during this
hospitalization and it was felt that her supraglottic edema
would ultimately resolve on a strict antireflux regimen with
strict anti-aspiration precautions and management of
secretions. Ultimately, one the supraglottic edema resolved,
it is thought that the patient may be able to have her trach
removed without need for a stent or more long-term trach
placement. The Interventional Pulmonary Service agreed. ENT
team, with Dr. [**Last Name (STitle) **], planned to see the patient again
prior to discharge to confirm long-range management plans.
The patient was started on b.i.d. Protonix IV and then
ultimately transitioned to Prevacid suspension b.i.d. through
the PEG tube.
CARDIOVASCULAR: The patient has a history of coronary artery
disease. She was continued on her aspirin and Lopressor.
Captopril was added and titrated up for blood pressure
control. This was thought to be especially important given
significant proteinuria noticed on urinalysis. The patient
also has an elevated protein:creatinine ratio. The patient
was intermittently hypertension throughout her
hospitalization at times to the 220s systolic, asymptomatic,
often in the setting of agitation and difficulty with the
trach. For the acute exacerbation she was treated with IV
Hydralazine. Following the placement of a new trach and
weaning from the vent, the patient's blood pressure did
improve, but remained consistently in the 150s to 160s
systolic. She was continued on her Lopressor and her ACE
inhibitor was gradually titrated up to control. Heart rate
in the 50s did not allow much room for titration of the beta
blocker.
INFECTIOUS DISEASE: In addition to the pneumonia noted
above, the patient was found to have Urinary tract infection
positive for yeast. She was treated with a seven-day course
of Fluconazole. As noted above, the patient had [**11-23**]
blood-culture bottles positive for Vancomycin-resistant
enterococcus. This was thought to be colonized, as it was
not replicable on repeat blood cultures. She was not treated
for this per se.
ENDOCRINOLOGY: The patient has a history of diabetes
mellitus with poorly controlled blood sugars. She was
initially maintained on just a regular insulin sliding scale.
She was later started on low-dose Glyburide with dramatic
improvement in her fingersticks.
NEUROLOGICAL: The patient had significantly depressed mental
status, poorly responsive for much of her MICU course,
ultimately deemed secondary to weaning from her sedatives.
She took a long time to awakened after being weaned off the
vent. Additional administration of Haldol and p.r.n.
narcotics perpetuated her depressed mental status. By the
time the patient was transferred to the floor, she was at her
baseline.
RENAL: The patient was noted to have proteinuria by
urinalysis and elevated protein:creatinine ratio. She was
started on an ACE inhibitor and should ideally have renal
followup at the time of discharge. This is attributable to
either hypertensive versus diabetic nephropathy versus other
etiology.
GASTROINTESTINAL: The patient was noted to have C. difficile
colitis. The patient was treated with a ten-day course of
Flagyl. She had persistently guaiac-positive loose stools.
This was thought to be secondary to GI bleed versus C.
difficile infection. Hematocrit gradually trended down, and
she was transfused two units of packed red blood cells to
which she responded appropriately. Hematocrit remained
stable for the remainder of her hospitalization. She should
be evaluated as an outpatient with a colonoscopy. The
primary care physician is aware of this.
PSYCHIATRY: The patient has history of depression treated
with Effexor at prior dose. The patient was noted to have
improved mood as per her family.
ACCESS: The patient had a right PIC placed for blood draws
and IV access.
PROPHYLAXIS: The patient was on Protonix and Pneumoboots
during this hospitalization.
COMMUNICATION: There were several family meetings held
during this hospitalization to keep the family up-to-date on
the progress of the interventions and long-term planning.
CODE STATUS: The patient was a full code.
Please see addendum to discharge summary for the remainder of
the hospital course following transfer to the medical floor,
as well as for long-term discharge planning and discharge
medications.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**Last Name (NamePattern4) 97564**]
D: [**2126-2-4**] 16:40
T: [**2126-2-4**] 16:46
JOB#: [**Job Number 97565**]
Name: [**Known lastname 183**], [**Known firstname 634**] Unit No: [**Numeric Identifier 15560**]
Admission Date: [**2126-1-24**] Discharge Date: [**2126-2-6**]
Date of Birth: [**2046-12-2**] Sex: F
Service: CARDIOTHOR
ADDENDUM: This is to continue discussing the [**Hospital 1325**]
hospital course after she was transferred out of the
Intensive Care Unit.
[**First Name8 (NamePattern2) 1693**] [**Known lastname **] was transferred out of the Intensive Care Unit
on the [**2126-2-4**]. She continued to do well on the
Floor and was completely stable. She was changed over to a
cool mist tracheostomy mask and her O2 saturations remained
stable. The only event that happened after her transfer were
on two occasions she tried to get out of bed and was unable
to do so. She ended up landing on the floor. There was no
head trauma and there were no noticeable injuries sustained
during those falls. Just to briefly go through her issues
while she was on Floor:
1. Pulmonary: As mentioned, her O2 saturations were stable.
She was seen by Ears, Nose and Throat who recommended that
she have strict aspiration precautions, take nothing by
mouth, keep her bed at greater than 45 degrees and there was
no further treatment that they recommended for her
supraglottic edema.
2. Cardiovascular: The patient was continued on Lopressor
50 twice a day and Captopril 50 three times a day. She was
hemodynamically stable, although if her blood pressure would
continue to increase, it might be worth considering
increasing the Captopril. Her heart rate will most likely
not tolerate increasing her Lopressor.
3. Hematologic: Her hematocrit remained stable while she
was on the Medical Floor. No further transfusions were
needed.
4. Endocrine: The patient had excellent glucose control on
Glyburide and a Regular insulin sliding scale.
5. Fluids, Electrolytes and Nutrition: The patient was
continued on her tube feeds at 60 cc per hour. The tube
feeds are Ultracal tube feeds as she was having in the
Intensive Care Unit.
6. Neurologic/Psychiatric: The patient was continued on
Effexor and it should be mentioned that narcotics,
Benzodiazepines and Haldol should be avoided in this patient.
7. Infectious Disease: The patient was continued on
Fluconazole for yeast. The last day of her Fluconazole will
be today, the [**2126-2-6**], and on Flagyl p.o. for
Clostridium difficile colitis. The last day of her Flagyl
course will be tomorrow, [**2126-2-7**]. The patient did
have one out of four blood cultures bottles with Gram
positive cocci with a question of whether it was VRE. It was
recommended that the patient have surveillance blood cultures
done in the nursing home facility.
DISCHARGE MEDICATIONS:
1. Regular insulin sliding scale.
2. Fluconazole 100 mg p.o. to stop on the [**2-7**]. Flagyl 500 mg p.o. q. eight hours to stop on the [**2-8**]. Glyburide 5 mg q. day.
5. Effexor 50 mg q. a.m.
6. Synthroid 150 micrograms q. day.
7. Prevacid suspension 30 mg twice a day.
8. Lopressor 50 mg twice a day.
9. Albuterol and Atrovent nebs q. four hours.
10. Ultracal tube feeds at 60 cc per hour.
11. Aspirin 325 mg q. day.
12. Dulcolax 10 mg p.o. or p.r. q. day.
13. Captopril 50 mg three times a day.
14. Tylenol 650 mg q. four to six hours p.r.n.
DISCHARGE DIAGNOSES:
1. Supraglottic edema.
2. Status post tracheostomy for question of tracheomalacia.
3. Coronary artery disease status post coronary artery
bypass graft.
4. Hypertension.
5. Diabetes mellitus.
6. History of aortic valve replacement due to aortic
stenosis.
7. Chronic renal insufficiency.
DISPOSITION: The patient will be discharged to [**Hospital3 15561**] on the [**2126-2-6**], where she will be followed
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from [**Hospital3 7005**] Group.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3570**]
Dictated By:[**Last Name (NamePattern1) 506**]
MEDQUIST36
D: [**2126-2-6**] 11:25
T: [**2126-2-6**] 11:34
JOB#: [**Job Number **]
|
[
"518.81",
"V45.81",
"V43.3",
"V09.0",
"507.0",
"599.0",
"V44.1",
"008.45",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.93",
"38.91",
"33.21",
"97.23",
"96.04",
"96.56"
] |
icd9pcs
|
[
[
[]
]
] |
12741, 13558
|
12163, 12720
|
1305, 1680
|
2779, 12140
|
1745, 2761
|
943, 1279
|
1697, 1722
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,322
| 156,276
|
40741
|
Discharge summary
|
report
|
Admission Date: [**2121-9-30**] Discharge Date: [**2121-10-7**]
Date of Birth: [**2043-12-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2121-10-1**] Cardiac cath
[**2121-10-2**] Redo mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**] Epic
bioprosthesis using the valve-sparing technique
History of Present Illness:
This is a 77yo female s/p mitral valve repair in [**2094**] who now
presents with worsening shortness of breath. She has chronic
atrial fibrillation and required placement of permanent
pacemaker in [**2119**]. Transesophageal echocardiogram in [**Month (only) **]
[**2120**] confirmed severe mitral regurgitation. Given significant
mitral regurgitation and congestive heart failure symptoms, she
has been referred for redo mitral valve surgery.
Past Medical History:
- Mitral regurgitation
- Congestive Heart Failure
- Chronic Atrial Fibrillation
- Hypertension
- Dyslipidemia
- Hypothyroidism
- Depression
- s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Valve repair [**2094**] at [**Location (un) 89082**]medical
center
- s/p PPM Placement [**2119**]
- s/p Right thoracentesis
- s/p Hysterectomy
- s/p Laparoscopic cholecystectomy
- s/p Bladder resuspension
- s/p Tonsillectomy
Social History:
Race: Caucasian
Last Dental Exam: Last year, full dentures
Lives with: Husband
Contact: [**Name (NI) **] [**Known lastname 89083**] Phone # [**Telephone/Fax (1) 89084**]
Occupation: Retired
Cigarettes: Smoked no [] yes [X] last cigarette 30+ yrs ago
Other Tobacco use: -
ETOH: < 1 drink/week [X] [**2-10**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
No premature coronary artery disease
Physical Exam:
Pulse: 56 Resp: 20 O2 sat: 96%
B/P Right: 143/78 Left:
Height: 5'6" Weight: 155lbs
Five Meter Walk Test #1_______ #2 _________ #3_________
General: Well-developed female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X] Well-healed left thoracotomy
Heart: RRR [] Irregular [X] Murmur [X] grade [**2-9**] sys
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [X]
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2121-10-1**] Cath: 1. Selective coronary angiography of this right
dominant system demonstrated no angiographically-apparent
flow-limiting stenoses. The LMCA, LAD, LCx, and RCA were all
without any significant coronary artery disease. 2. Resting
hemodynamics revealed mildly elevated right-sided filling
pressures with an RVEDP of 15 mmHg. Left-sided filling
pressures were also moderately elevated with a PCWP of 22 mmHg.
Pulmonary artery pressures were moderately elevated with a PAS
pressure of 55 mmHg. There was borderline systemic systolic
arterial hypertension with a central aortic pressure of 140/57,
mean 88 mmHg. The cardiac index was preserved at 2.4 L/min/m2
(using an assumed O2 consumption).
[**2121-10-1**] Chest CT: 1. No significant calcification of the
thoracic aorta. 2. Large right non-hemorrhagic pleural effusion
with associated compressive atelectasis. Small left
non-hemorrhagic pleural effusion. 3. Right paratracheal lymph
node measuring 16-mm (2:24) with mutliple additional small
mediastinal/prevascular nodes. 4. 5-mm left apical nodule (4:32)
should be followed-up with CT in 12 months if patient does not
have a history of smoking or malignancy. Otherwise, follow-up
with CT in 6 months is recommended.
[**2121-10-2**] Echo: PRE-BYPASS: The left atrium is elongated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. Mild spontaneous echo contrast is present in the left
atrial appendage. The right atrium is markedly dilated. No
atrial septal defect is seen by 2D or color Doppler. There is a
coronary sinus which appears dilated at > 1.5 cm. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is
moderate valvular mitral stenosis (area 1.0-1.5cm2). Moderate to
severe (3+) mitral regurgitation is seen. There is mild to
moderate ([**1-5**]+) tricuspid regurgitation. The tricuspid annulus
measures 2.7 cm in the septo-lateral dimension. There is no
pericardial effusion. Dr.[**Last Name (STitle) 914**] was notified in person of the
results on [**2121-10-2**] at time of surgery. POST-BYPASS: 1. Improved
[**Hospital1 **]-ventricular systolic function. 2. Bioprosthetic valve in
mitral position, well seated and stable with good lealfl;et
excursion. 3. Mean transmitral gradient is 4 mm Hg. 4. Moderate
TR and mild AI. 5. No other change.
Brief Hospital Course:
Mrs. [**Known lastname 89083**] was admitted preoperatively for Heparin bridge and
cardiac cath. On day of admission she underwent routine
pre-operative work-up. On [**10-1**] she underwent a cardiac cath
which revealed no coronary artery disease. In addition, she
underwent a chest CT. On [**10-2**] she was brought to the operating
room where she underwent a redo mitral valve replacement. Please
see operative report for surgical details. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one she was
started on beta-blockers and diuretics and gently diuresed
towards he pre-op weight. EP interrogated pacemaker on post-op
day 1 and it was functioning appropriately. Later this day she
was transferred to the step-down floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol.
Coumadin was restarted for chronic atrial fibrillation and
titrated for goal INR. She remained slightly anemic post-op with
discharge HCT of 28.6. she worked with physical therapy during
her post-op course for strength and mobility. She continued to
make good recovery and was discharged to rehab on post-op day
five with the appropriate medications and follow-up
appointments. Coumadin dose of 2.5mg will be titrated by rehab
for goal INR 2-3.0. Upon discharge from rehab, rehab to set up
long-term f/u for Coumadin with PCP.
Medications on Admission:
Warfarin 2.5mg 4x/wk, 5mg 3/wk **Last Dose of Coumadin:
Friday, [**2121-9-26**]**
Sertraline 50mg daily
Tricor 48mg daily
Levothyroxine 100mcg daily
Furosemide 40mg daily
Lisinopril 2.5mg daily
Simvastatin 10mg daily
Metoprolol 12.5mg [**Hospital1 **]
Evista 60mg daily
Vitamin D daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
9. raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate for goal INR 2-3.3.
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
13. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Mitral regurgitation s/p Redo Mitral valve replacement
Past medical history:
- Congestive Heart Failure
- Chronic Atrial Fibrillation
- Hypertension
- Dyslipidemia
- Hypothyroidism
- Depression
- s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Valve repair [**2094**] at [**Location (un) 89082**]medical
center
- s/p PPM Placement [**2119**]
- s/p Right thoracentesis
- s/p Hysterectomy
- s/p Laparoscopic cholecystectomy
- s/p Bladder resuspension
- s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol/Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Left groin - healing well, no erythema or drainage
Edema - trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2121-11-18**] at 1:30PM
Cardiologist: Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9035**] on [**11-3**] at 11:00am
Thoracic surgery: Dr [**Last Name (STitle) **] on [**11-18**] at 11:00am
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**4-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: chronic atrial
fibrillation
Goal INR 2-3.0
First draw [**2121-10-8**]
**Please arrange for coumadin follow-up prior to d/c from
rehab**
Completed by:[**2121-10-7**]
|
[
"401.9",
"996.02",
"285.9",
"427.31",
"V58.61",
"V17.3",
"424.0",
"E878.2",
"244.9",
"272.4",
"428.0",
"311",
"V45.89",
"416.8",
"518.0",
"511.89",
"V53.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"39.61",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
8714, 8744
|
5632, 7123
|
330, 507
|
9273, 9503
|
2674, 5609
|
10426, 11291
|
1835, 1873
|
7461, 8691
|
8765, 8820
|
7149, 7438
|
9527, 10403
|
1888, 2655
|
271, 292
|
535, 981
|
8842, 9252
|
1452, 1819
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,463
| 134,789
|
54696
|
Discharge summary
|
report
|
Admission Date: [**2164-7-28**] Discharge Date: [**2164-8-14**]
Date of Birth: [**2121-10-24**] Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 65686**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
Stereotactic brain biopsy
History of Present Illness:
This is a 42 year old woman with a history of MS diagnosed in
[**Month (only) 958**] of this year when she had recurrent vertigo. She began to
have left sided weakness 3 days ago. She was treated with
Solu-Medrol for MS flair up. When she did not improve, she went
to [**Hospital 8641**] hospital and her Neurologist recommended an MRI brain.
This showed a large ring enhancing lesion on the right. She was
given Solu-Medrol, Decadron and 1g Fosphenytoin. She was
transferred to [**Hospital1 18**] for further management.
She is usually ambulatory. She had a colonoscopy and mammogram
last year without abnormal finding. She reports
headache,posterior RLE numbness to the ankle. She denies fever
chills,pain, nausea.
Past Medical History:
MS, ulcerative colitis, asthma, bony tumor removed for her right
ear with a mastoidectomy > 10 years ago. Pathology unknown.
Social History:
She is right handed. She lives with her husband, She works
cleaning houses. She does not smoke and she rarely uses ETOH.
Family History:
Family Hx:Her maternal grandmother had lung CA.
Physical Exam:
On Admission:
Gen: WD/WN, NAD
HEENT: Pupils: 2-1.5 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam
Orientation: Oriented to person, place.
Language: Speech slurred. Naming intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII:Left facial droop.
VIII: Hearing intact to voice.
XII: Tongue midline without fasciculations.
Motor: [**Doctor First Name **] [**Hospital1 **] tri grip IP [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] AT
L 0 0 0 0 2 3 3 3
R 4+ 4+ 4+ 4+ 4+ 5 5 5
Sensation: Intact to light touch
Toes downgoing right, upgoing on left
Coordination: normal on finger-nose-finger on the right
AT discharge:
VS: Tmax-98.6 Tcurrent-98 BP-112/17 HR-80 RR-18 O2sat-97% on RA
GEN: NO acute distress. Pleasant demeanor.
HEENT: PERRL, EOMI, moist mucous membranes, clear oropharynx
NECK: No JVD, no lymphadenopathy
CARDIO: RRR, no murmurs, rubs, gallops
Lungs:Decreased breath sounds at bilateral lung bases. Dry
crackles at right lung base. No wheezing.
Abdomen: Soft, nontender, nondistended, normoactive bowel sounds
Extremities: No edema or cyanosis.
Neuro: Cranial nerves II-XII grossly intact with exception of
left facial droop. 4/5 strength in left upper and lower
extremities. 5/5 strength in right upper and lower extremities.
Pertinent Results:
Admission Labs:
[**2164-7-29**] 12:38AM BLOOD WBC-12.2* RBC-3.68* Hgb-11.9* Hct-35.4*
MCV-96 MCH-32.4* MCHC-33.7 RDW-13.2 Plt Ct-334
[**2164-8-4**] 05:55AM BLOOD Neuts-83.3* Lymphs-9.4* Monos-6.8 Eos-0.1
Baso-0.3
[**2164-7-29**] 12:38AM BLOOD PT-12.2 PTT-26.0 INR(PT)-1.1
[**2164-7-29**] 12:38AM BLOOD Glucose-163* UreaN-11 Creat-0.6 Na-142
K-3.5 Cl-107 HCO3-26 AnGap-13
[**2164-7-29**] 12:38AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0
Discharge Labs:
[**2164-8-14**] 06:00AM BLOOD WBC-5.1 RBC-3.02* Hgb-9.8* Hct-28.9*
MCV-96 MCH-32.3* MCHC-33.7 RDW-14.1 Plt Ct-193
[**2164-8-14**] 06:00AM BLOOD PT-12.6* PTT-29.9 INR(PT)-1.2*
[**2164-8-14**] 06:00AM BLOOD Glucose-85 UreaN-7 Creat-0.4 Na-134 K-4.7
Cl-97 HCO3-28 AnGap-14
[**2164-8-14**] 06:00AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
Microbiology:
Blood cultures [**2164-8-10**]: pending at time of discharge, NGTD
[**2164-7-29**] MRI brain-WAND study
1. Unchanged heterogeneously enhancing lesion in the right
frontal
region with significant edema in the basal ganglia and mass
effect as
described above. Fiducial markers are in place.
2. Unchanged right cerebellar enhancing lesion with mild
vascular enhancement, adjacent to the cerebellar nodule on the
right, possibly consistent with a developmental venous anomaly,
a second lesion in this region cannot be completely ruled out.
CT head [**2164-7-29**]
A large right frontotemporal mass with extensive surrounding
vasogenic edema and mass effect and leftward shift of midline
structures to approximately 8 mm. Subfalcine and uncal
herniation. The above findings in conjunction with the prior
MRI are concerning for a tumefactive multiple sclerosis or a
primary malignant tumor (including primary versus secondary).
The above findings were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3742**], at
approximately 1:30 a.m. and immediately after the CT study.
[**2164-8-3**] MRI Brain: 1. Limited study for surgigal planning
showing mild interval improvement in the ring-enhancing mass in
the left frontal lobe with reduction in degree of mass effect.
2. Relatively stable appearance of right cerebellar enhancing
focus,
suggesting multifocal disease.
[**2164-8-3**] CT head postop: IMPRESSION:
1. Pneumocephalus and small amount of acute blood products in
the right
frontal region after biopsy.
2. Right frontotemporal edema due to large mass with subfalcine
herniation, better-delineated on MRI of earlier today. Mild
effacement of the right perimesencephalic cisterns is improved
from [**2164-7-29**].
[**2164-8-9**] Chest X-ray (PA and lat)
CONCLUSION: New airspace consolidation at the base of both
lungs, but more
prominent in the right lower lobe, suggestive of multifocal
pneumonia or
aspiration.
[**2164-8-9**] LENI's:
IMPRESSION:
Deep venous thrombosis within the left gastrocnemius and soleus
veins.
[**2164-8-11**] CT ABD & PELVIS W/O CON
IMPRESSION:
1. No acute intra-abdominal or intra-pelvic process.
3. Bilateral lower lobe consolidative opacities, right greater
than left,
possibly secondary to compressive atelectasis given the adjacent
pleural
effusions, although infection or aspiration could have a similar
appearance.
3. Small quantity of sludge within the gallbladder. No
associated
gallbladder wall thickening to suggest acute cholecystitis.
Brief Hospital Course:
Ms. [**Known lastname **] is a 42 yo female with a history of multiple
sclerosis, ulcerative colitis, and asthma who presented with a
rapid decline in strength and level of consciousness and found
to have Primary CNS B cell lymphoma after stereotactic brain
biopsy. Her course was complicated by DVT, probable PE, and
pneumonia.
Active Diagnoses:
# Primary CNS B cell lymphoma: Ms. [**Known lastname **] was transfered from
[**Hospital 8641**] Hospital to the NSICU. Her MRI was entered into our
system. She was on Decadron for cerebral edema. Her speech
became more slurred during the night and Decadron was increased
to 10mg Q6 hours. Mannitol was started. CT head was done to rule
out hemorrhage as her exam was dramatically worse then what was
portrayed in the transfer notes. It was negative for hemorrhage
but showed a frontotemporal mass. She was started on Dilantin
on the neurology service given seizure at OSH. With medical
management her exam improved with less weakness on her left.
Neuromedicine requested a biopsy due to the fact that review of
OSH records revealed an LP that did not suggest MS. They were
concerned for tumor. On the night of [**8-2**], she was taken to the
OR on [**8-3**] for a stereotactic brain biopsy. Preliminary
pathology was reviewed with Heme-Path and thought to be primary
CNS B-cell lymphoma. Postoperative CT head demonstrated mild
pneumocephalus and small amount of acute blood products in the
area of the biopsy. Patient was transferred to the Neuro-SDU.
Her exam remained stable. On [**8-4**], patient was transferred to
the floor. She continued on high dose steroids. Over the next
several days her exam improved with improvement of her left
facial droop and left-sided weakness. She was transitioned from
Dilantin to Keppra for seizure prophylaxis. Her dexamethasone
was tapered to dexamethasone 4 mg twice daily without further
taper for the next week. She will be readmitted to the service
next week on [**8-21**] for chemotherapy and second dose of
methotrexate.
# DVT/PE: Patient developed pleuritic right sided
chest/abdominal pain and tachycardia. It was suspected that she
had a PE, so lower extremity ultrasound was obtained which
confirmed left lower extremity DVTs. Unable to perform CTA chest
given concern for contrast affecting renal function while
dosing MTX. Patient was treated with heparin drip then
transitioned to Lovenox for discharge. She was given dilaudid as
needed for pain control.
# Health care associated pneumonia: Patient developed fever and
hypoxia during her hospital course and was found to have right
pleural effusion and bilateral opacities worrisome for
pneumonia. Patient was treated for HCAP with cefepime and
vancomycin. She is discharged with a PICC line and will continue
cefepime and vancomycin for 4 more days with last dose to be
completed on [**2164-8-17**] to complete an eight day course. She
remained afebrile for >48 hours prior to discharge.
# Constipation: Most likely secondary narcotics and inactivity.
Pt was given senna, colace, miralax, in addition to prn
lactulose.
# Abdominal pain: Likely referred from right-sided pleuritic
pain as discussed above. CT abdomen showed no acute process.
Pt's pain improved when treated for thrombosis and pneumonia.
# Anemia: No active s/s of bleeding. Most likely related to
phlebotomy, acute illness and MTX treatment.
Inactive Diagnoses:
# Ulcerative colitis: Held Mesalamine and discharged with plan
to continue to hold for now given as it can interfere with
methotrexate.
# Asthma: No signs of exacerbation. Continue singulair, advair,
albuterol prn.
Transitional Issues:
1. Code status: Full
2. Contact: [**Name (NI) 4906**] [**Name (NI) **]
3. Med Changes:
- START Vancomycin 1 gram every 12 hours for 4 more days (last
day = [**8-17**])
- START Cefepime for 2 gram every 8 hours for 4 more days (last
day = [**8-17**])
- START Lovenox 60mg SC injections twice daily
- START Levetiracetam 500mg by mouth twice daily
- START Dexamethasone 4mg by mouth twice daily
- START Omeprazole 40mg by mouth daily
- START Calcium + Vit D twice daily
- START Dilaudid 4mg by mouth every 4 hours as needed for pain
**This medication can cause sedation and should not be taken
when doing heavy activity.
- START Docusate sodium 100mg tablet three times per day (for
constipation)
- START Senna 2 tablets daily as needed for constipation
- START Miralax packet once daily as needed for constipation
- START Ondansetron 4mg by mouth every 8 hours as needed for
nausea
- STOP Mesalamine
Please continue the other medications you were taking prior to
this admission.
4. Follow up: with oncology with readmission next week, Dr.
[**Last Name (STitle) 6570**] for additional MTX
5. Pending studies: final pathology read for tumor biopsy
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Mesalamine 1200 mg PO TID
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
3. Montelukast Sodium 10 mg PO DAILY
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Meclizine Dose is Unknown PO Frequency is Unknown - not
taking, rarely
7. DiphenhydrAMINE Dose is Unknown PO Frequency is Unknown -
not taking
8. Acetaminophen 650 mg PO Q6H:PRN pain or fever > 101.4
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
8. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation.
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 4 days: day 1 = [**8-10**], last
day [**8-17**], to complete 8 day course.
12. cefepime 2 gram Recon Soln Sig: Two (2) Recon Soln Injection
Q8H (every 8 hours) for 4 days: day 1 = [**8-10**], last day [**8-17**], to
complete 8 day course.
13. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
14. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours).
15. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
16. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain: do NOT take while driving or doing
heavy activity .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary:
1. CNS B-Cell Lymphoma
2. Deep vein thrombosis
3. Pneumonia
Secondary:
1. Ulcerative colitis
2. Asthma
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:
Mrs. [**Known lastname **],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You came to the hospital for weakness in your legs and were
found to have a brain lesion. A stereotactic brain biopsy was
performed and found that you have CNS B-cell Lymphoma. You were
started on steroids to reduce the swelling in your brain and
your weakness gradually improved. Chemotherapy was started with
Methotrexate. You also developed blood clots in your leg and
most likely had a blood clot in your lungs causing you pain in
your back. You developed a fever and a CXR showed that you
probably have a Pneumonia. You were started on antibiotics and
improved. A PICC line was placed so you can continue antibiotics
as an outpatient.
The following medications were changed during this admission:
- START Vancomycin 1 gram every 12 hours for 4 more days (last
day = [**8-17**])
- START Cefepime for 2gram every 8 hours for 4 more days (last
day = [**8-17**])
- START Lovenox 60mg injections twice daily
- START Levetiracetam 500mg by mouth twice daily
- START Dexamethasone 4mg by mouth twice daily
- START Omeprazole 40mg by mouth daily
- START Calcium + Vit D twice daily
- START Dilaudid 4mg by mouth every 4 hours as needed for pain
**This medication can cause sedation and should not be taken
when doing heavy activity.
- START Docusate sodium 100mg tablet three times per day (for
constipation)
- START Senna 2 tablets daily as needed for constipation
- START Miralax packet once daily as needed for constipation
- START Ondansetron 4mg by mouth every 8 hours as needed for
nausea
- STOP Mesalamine
Please continue the other medications you were taking prior to
this admission.
Followup Instructions:
Please follow-up with the following appointment:
Department: NEUROLOGY
When: FRIDAY [**2164-9-28**] at 1 PM
With: [**Name6 (MD) 4677**] [**Name8 (MD) 4678**], MD [**Telephone/Fax (1) 3506**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will return to the hospital next week on [**2164-8-21**] prior to
your next dose of Methotrexate. After that hospitalization, we
will help to arrange further follow-up appointments.
Completed by:[**2164-8-14**]
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16,373
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49993
|
Discharge summary
|
report
|
Admission Date: [**2197-1-31**] Discharge Date: [**2197-2-13**]
Service: MEDICINE
Allergies:
Tetanus Antitoxin / Penicillins / Ethambutol
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a [**Age over 90 **] year old female with a history of COPD,
diastolic heart failure, who was recently admitted for
pneumonia, DM II, and aortic stenosis who presented with three
days of cough. Initially, the cough was productive of sputum
(unknown color) but for the past 24 hours before admission,
cough was dry. She denied any fever, sore throat, body aches,
sinus congestion or any change in her breathing. She received a
flu shot this year.
On review, patient denied any chest pain or peripheral edema.
.
In the ED, she was treated with albuterol & ipratroprium bromide
nebulizers, nitroglycerin x 2, aspirin 325 mg, lasix 40mg,
solumedrol 125 mg IV, and levofloxacin 500mg. A chest xray was
performed that revealed bronchiectasis in the upper lobe
lesions, with no areas of consolidation. Troponin was 0.01. EKG
showed LBBB pattern.
.
In the MICU, she was tachypneic. She has been receiving
nebulizers and sputum cultures were positive for MRSA. Patient
remained on levofloxacin and vancomycin was started on [**2197-2-3**].
Her oxygen saturations were 94% on 3 liters nasal canula.
Past Medical History:
--COPD: Last spirometry [**6-14**]: Results are consistent with a
restrictive ventilatory defect. FVC 66% of predicted; FEV1 68%
of predicted; FVC/FEV1 1.03. Results are consistent with a
restrictive ventilatory defect. Cannot rule out obstructive gas
trapping.
--Bronchiectasis: history of atypical mycobacteria on sputum
culture in [**2191**]- followed by Dr. [**Last Name (STitle) 21848**].
--Hypertension: On stable regimen on atenolol, hctz,
nifedipine.
Concern of CP in association with elevated blood pressure in
past.
--Aortic stenosis: ECHO in [**2195-4-10**]-The left atrium is mildly
dilated, left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. The aortic valve leaflets
are moderately thickened. Mild aortic stenosis is present. Mild
(1+) aortic regurgitation is seen. Compared with the findings of
the prior study of [**2193-11-28**], there has been no significant
change.
--Cholelithiasis/cholangitis: Status post ERCP with
sphincterotomy/stent placement and removal (d/c summary [**5-13**]),
also s/p cholecystectomy.
--Diabetes
Social History:
Moved from the [**Location (un) 3156**] 26 years ago. Lives alone with home
services, where someone sees her every day. She uses a walker at
baseline. She is on home O2 (2L by NC). Denies current tobacco,
alcohol and illicit drug use. Smoked previously, quit in [**2175**].
Family History:
Non-contributory.
Physical Exam:
(on transfer):
VS: T 96.8, HR 57-77, BP 128-163/46, RR 18-29, O2sat: 92-97% on
3L nasal canula; I/O: 580/965, net:-385
GENERAL: Pleasant elderly Caucasian female who is quite anxious.
Not using accessory muscles to breath.
SKIN: Warm and dry.
HEENT: Sclerae are anicteric, conjunctiva without injection,
MMM. No cervical adenopathy. Purple lesion in left inner cheek.
NECK: No JVP, no adenopathy, no thyromegaly.
LUNGS: Crackles prominent in right lung, throughout. Coarse
breath sounds. Crackles at the bases. Inspiratory wheezes
noted.
HEART: Regular with 3/6 holosystolic murmur at apex.
ABD: Soft, with active bowel sounds throughout. Tender in
right upper quadrant to deep palpation.
EXTREMITIES: Warm and well perfused. No edema. 2+ peripheral
pulses.
Pertinent Results:
Imaging:
CXR ([**2197-2-4**]): Mild vascular congestion developed between
[**1-31**] and 24, unchanged. No pulmonary edema. Pleural
effusion, if any, is minimal, on the right. Heart size top
normal. No consolidation to suggest pneumonia. No
pneumothorax.
.
CTA ([**2197-1-31**]): 1. No evidence of pulmonary embolism. 2.
Bibasilar tree-in-[**Male First Name (un) 239**] opacities, which are somewhat decreased
since [**3-9**], [**2196**], but may represent an indolent infection. 3. Prominent
central pneumobilia, incompletely evaluated, of uncertain
etiology.
.
ECHO ([**2197-1-31**]): EF 60-70%. The left atrium is normal in size.
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 number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is moderate to severe
aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate ([**1-10**]+)
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 no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2196-2-1**], the severity of mitral regurgitation has
increased slightly and estimated pulmonary artery systolic
pressures are higher.
.
V/Q scan ([**2197-1-31**]): Severely limited study secondary to lack of
a ventilation study. Bilateral segmental defects are
indeterminate in etiology.
.
Chest Xray ([**2197-1-31**]): Allowing for differences in technique,
there has been near complete resolution of bilateral upper lobe
opacities from [**2196-12-7**]. Mild bronchiectasis in these regions
remain. There are no new areas of consolidation. The surrounding
soft tissue and osseous structures are stable.
.
cxr [**2-7**]: PA AND LATERAL CHEST X-RAY: The cardiac silhouette,
mediastinal and hilar contours are normal and stable. The
pulmonary vasculature is normal and there is no pneumothorax.
Reticulonodular opacities in bilateral lung apices, right middle
and lower lobes are stable and correspond with recent Chest CT,
consistent with chronic MAC. A tiny right pleural effusion is
slightly smaller than on prior exam. No new consolidations are
noted. The surrounding soft tissue and osseous structures are
stable.
IMPRESSION: No significant interval change in the appearnace of
the chest. Multifocal reticulonodular opacities are stable,
consistent with known chronic MAC.
.
labs:
[**2197-1-31**] 12:25AM D-DIMER-768*
[**2197-1-31**] 12:25AM WBC-15.5* RBC-3.85* HGB-12.7 HCT-36.6 MCV-95
MCH-33.1* MCHC-34.8 RDW-14.8
[**2197-1-31**] 12:25AM CK-MB-NotDone
[**2197-1-31**] 12:25AM cTropnT-<0.01 proBNP-1077*
[**2197-1-31**] 12:25AM GLUCOSE-110* UREA N-29* CREAT-1.4* SODIUM-136
POTASSIUM-5.9* CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
Brief Hospital Course:
Patient is a [**Age over 90 **] year old woman with a history of COPD, diastolic
heart failure, diabetes, aortic stenosis, who has been recently
admitted for pneumonia presents with an exacerbation of COPD and
MRSA poitive pneumonia. On transfer, being transferred on
vancomycin and levofloxacin.
.
1) Dyspnea: The patient presented with dyspnea and was
ininitally in the MICU as she was tachypneic. She had a cta and
VQ scan and was ruled out for PE. The patient was initially
treated with levofloxacin, and with MRSA sputum cultures
positive, vancomycin was added. She was stable and transferred
to the floor and continued on levofloxacin (started on [**1-31**]) and
vancomycin (started on [**2-3**]). In addition to her infection the
patient has known COPD and rhonchorous and wheezing on
examination. She was treated with nebulizers and steroids. As
she improved her steroids were tapered. Given her long-standing
respiratory history she will have close follow-up with her
pulmonologist as an outpatient.
.
2) Hypertension: The patient was initially hypertensive during
the intial part of hospitalization requiring nitro gtt. As her
blood pressure improved she was started on imdur, hydral,
metoprolol, and nifedipine, given the difficulty in controlling
her pressure with single agents. Her pressures continued to be
elevated and she was given increased doses of nifedipine and
hydral. At discharge her blood pressure was well-controlled on
multiple agents and she will continue imdur, hyral, metoprolol
and nifedipine. She will have close outpatient follow-up and her
blood pressure should be monitored then.
.
3) CHF: The patient had an EF between 60-70% on cardiac ECHO on
[**2197-2-3**], with moderate AR and AS, with prolonged mitral
deceleration time. She remained euvolemic throughout her course
and never required lasix. Her home lasix was started and she
will continue this as an outpatient.
.
4) Decreased renal function: The patient presented with a
creatinine of 1.4, increased from her baseline of 0.9. The
etiology was unclear, though with renally dosed medications the
patient improved towards her baseline.
.
5) Leukocytosis: The patient developed an increased white count
during her stay and this was attributed to a combination of
infectious process (+MRSA) and steroid initiation. Her blood
and urine cultures were negative and the patient was afebrile.
Her white count continued to trend down by discharge.
.
6) Pneumobilia: Per CTA report, the patient had pneumobilia. GI
was consulted and they said with ERCP (patient had this in the
past), this finding can be expected. The patient had some
abdominal discomfort during her course, mostly in right upper
quadrant, though this remained stable and her LFT's were
unremarkable. The patient was stable at discharge and was
comfortable.
.
7) Purple mouth sores: During the physical exam the patient was
noted to have small purple lesion on inner left cheek. The
diagnosis and duration of these lesions is unclear, though the
patient may need a biopsy as an outpatient.
.
8. atypical chest pain: The patient developed some chest pain,
that was reproducible on exam and seemed not to be acs. Her
enzymes were slighty increased, but trended down and were never
positive. Given the reproducibility this was likely
musculoskelatal. She will continue pain management as an
outpatient.
.
9. Abdominal Pain: The patient continually complained of
abdominal pain, that seemed to be chronic. She had slightly
elevated lipase, so this may have been related to pancreatitis.
She was limited in her diet and she improved. Her lipase
trended down and she had no further issues prior to discharge.
.
10) Diabetes Mellitus: The patient has diet controlled
diabetes. While on steroids she was on sliding scale insulin and
when off steroids her sugars improved. She may need oral agents
in the future and this should be followed closely as an
outpatient.
Medications on Admission:
(on admission):
1. ALBUTEROL 90MCG--2 puffs four times a day
2. AMBIEN 10MG PRN
3. ASPIRIN 81 mg QOD
4. ATENOLOL 25 mg QDAY
5. ATROVENT 18 mcg/Actuation--one puff twice a day
6. CALCIUM WITH VITAMIN D 500-125 TID
7. DIAZEPAM 2 mg qday
8. FLEXERIL 10MG qHS PRN
9. FUROSEMIDE 10 mg daily
10. MUCINEX 600 mg--1 tablet(s) by mouth twice a day
11. MULTIVITAMIN
12. NIFEDIPINE XR 30 MG daily
13. NITROGLYCERIN 0.4 mg PRN
14. PROTONIX 40 mg qday
15. PULMICORT 0.5 mg/2 mL--1 ampule 2 ml inhalation [**Hospital1 **]
16. QUININE SULFATE 325 MG qHS
17. RANITIDINE 150 MG [**Hospital1 **]
Discharge Medications:
1. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
Disp:*qs ML(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Budesonide 0.5 mg/2 mL Solution for Nebulization Sig: One (1)
ML Inhalation [**Hospital1 **] (2 times a day): pulmicort.
5. Diazepam 2 mg Tablet Sig: One (1) Tablet PO QDAY ().
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
four times a day.
10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed: ambien.
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. CALCIUM 500+D 500-125 mg-unit Tablet Sig: One (1) Tablet PO
three times a day.
14. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
15. Pulmicort 0.5 mg/2 mL Solution for Nebulization Sig: One (1)
Inhalation twice a day.
16. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*qs Cap(s)* Refills:*2*
17. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
18. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO three times
a day: 20 mg three times a day.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
1. COPD
2. MRSA pneumonia
3. bronchiectasis
4. Hypertension
5. Steroid induced diabetes (and baseline diet controlled
diabetes)
6. Anemia
7. Pancreatitis
Discharge Condition:
stable, tolerating medications
Discharge Instructions:
1. You were admitted for shortness of breath, and noted to have
a respiratory infection. You were treated with antibiotics.
You also were noted to have a copd exacerbation and were treated
with steroids. You also had elevated blood pressure, so several
medications were started. New medications include: isosorbide
dinitrate, hydralazine and metoprolol. You will not take
atenolol and will take a higher dose of nifedipine. You will
not take atrovent inhalers, instead you will use tipratroprium.
Please follow the new list we give you.
.
2. You were on steroids so had increased sugars, based on this
you need your glucose closely followed by Dr. [**Last Name (STitle) **].
.
3. Attend all appointments
.
4. Please return for fevers, chills, chest pain, dizziness,
vomiting, inability to take medications or any concerns.
Followup Instructions:
1. Please attend your appointment with Dr. [**Last Name (STitle) **] and her nurse
practitioner as follows: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 30886**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2197-2-15**] at 3:30 pm
2. Please attend your pulmonary appointment on [**Location (un) **] of
[**Hospital Ward Name **] as follows: Provider: [**Name10 (NameIs) 1571**] BREATHING TEST
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2197-3-2**] 2:00. This is followed by
the following appointment: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2197-3-2**] 2:30
|
[
"285.29",
"288.60",
"424.1",
"311",
"584.9",
"V09.0",
"428.0",
"585.9",
"403.91",
"577.0",
"300.00",
"530.81",
"482.41",
"V10.43",
"428.30",
"786.59",
"250.00",
"496",
"528.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13118, 13193
|
6718, 10658
|
272, 279
|
13391, 13424
|
3703, 6695
|
14300, 14987
|
2880, 2899
|
11287, 13095
|
13214, 13370
|
10684, 11264
|
13448, 14277
|
2914, 3684
|
212, 234
|
307, 1413
|
1435, 2572
|
2588, 2864
|
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